Evaluating the Effectiveness of Hand Washing in Preventing Hospital Acquired InfectionsThis essay will evaluate the effectiveness of Hand Washing (HW), one of the interventions used by the National Health Services (NHS), to prevent HAIs. This evaluation has been carried out by reviewing and comparing current national and global Hand Washing (HW) policies, as well are critically evaluating some of existing studies that supports evidence on HW efficacy as prevention and control management against Hospital Acquired Infections (HAIs). The essay will also, discuss behaviour change method NHS applies to nursing staff as encouragement for hand washing compliance. As well as, emphasise the implications nursing staff might legally be accountable if failing to comply Infections Prevention and Control within their activities according to National Institute for Health and Care Excellence (NICE) ethics of professionalism, the Nursing and Midwifery Council (NMC) Code and what consequences nurses’ career face if failing to care for patients according to UK’s laws and legislations.Hospital Acquired Infections (HAIs) continues to be a major concern in British hospitals. The 2011 prevalence review showed that 6.4% of hospital patients that is 1 in every 16 does contract an infection while in hospital (Mackley, et al., 2018). Between 2012 and 2018 there was an increase in the number of people who acquired HAIs which concerns, caused reason for political debate in British parliament (Mackley, et al., 2018). Elderly and very young children patients are more likely to be vulnerable to infection due to their age, illness, comorbidities, or the treatment for their condition (Department of Public Health, 2019). HAIs are, as the name suggests, those that patients acquire as a result of their stay in hospital. The main ways by which people get into contact with the hospital are getting admitted due to sickness, working in the hospital and visiting or caring for the sick as a guardian. There are many interventions and policies that are used to prevent HAIs in UK NHS hospitals. The history of HAIs started with nosocomial infections which is a medical term used to describe infections caught by patients, staff or visitors in a hospital. These infections are caused by microorganisms which in some cases are resistant to antibiotics (MedicineNet, 2019). Microorganisms are spread to others through four common routes of transmission which are; direct and indirect contact, airborne spread, respiratory droplets, and common vehicle (Collins, 2008). For example, surgical wounds, catheter drainage or a more direct contamination through skin-to-skin contact during a healthcare treatment intervention (Nice.org.uk, 2019). The most common reported cases of HAIs include Methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium Difficile (C.difficile) (Public Health England, 2016) all of them easily transmitted. The 6 most common types of HAIs are; – Pneumonia and other respiratory infections (22.8%),- Urinary tract infections (17.2%), – Surgical site infections (15.7%), – Clinical sepsis (10.5%), gastrointestinal infections (8.8%), – Bloodstream infections (7.3%) (NICE, 2016). Microorganisms responsible for HAIs are easily passed from infected patient or contaminated objects on the ward to another by hands subsequently causing infection (NHS Infection, Prevention and Control 2016). HAIs can infect any hospitalised patients who because these patients are at increased risk of HAIs due to their low immune systems (PatientCareLink, 2018). This can lead to complications such as staying longer in hospital, needing for further treatments and development of disabilities or even death. It was reported in The Daily Telegraph Business Reporter (2015) that HAIs contributed to 5000 deaths and cost £1 billion per year to NHS. The impact HAIs has caused to date, has raised government major concerns and caught media attention. As result, the UK government has created external agencies, boards and commissioners who are accountable to develop tools and guidance for controlling and prevention management of HAIs in hope of offering safer and high-quality standard healthcare services in Britain to the public (National Audit Office, 2009). For example, the duties of the Care Quality Commission (CQC) as an independent regulator, are to register health and adult social care service providers in England, to inspect whether standards are being met or not and monitor healthcare providers level of treatment and patient care (Care Quality Commission, 2019a). CQC carries out HW audits to ensure that staff are trained in HW techniques and that hospitals have adequate HW facilities available and easily accessible to all (Care Quality Commission, 2019b). Another is NICE, who has a fundamental role in supporting the government for management of control and prevention of HAI. NICE responsibilities include production of evidence-based guidelines and offer health, public health and social care practitioners’ advice with the aim of improving to improve the standards of patient care (NICE, 2019). Such guidelines cover preventing and controlling HAIs in patients in primary and community care settings as well as providing a blueprint for the infections prevention and control precautions that should be applied by everyone involved in delivering NHS care and treatment (NICE, 2017). Some of the preventive methods used by NHS hospitals to avoid the transmission and further spreading of HAIs are;- Isolation- The use of Personal Protection Equipment (PPE)- Decontamination of medical equipment- Environment hygiene- Hand hygiene (Minnaar,2008).HW is the act of cleaning hands for the purpose of removing dirt, soil, and microorganisms. The correct method to do this is with soap and water, or other detergents containing an antiseptic agent with hands rubbing without any jewellery. For the procedure to be effective, it should last at least 60 seconds (World Health Organization, 2009). Hands could also be cleaned with an alcohol-gel sanitiser (Minnaar, 2008) although there is still controversy whether it is has the same effectiveness as to washing hands with water and soap. The Centre for Disease Control and Prevention (CDC) (2018) recommends that hands are specifically cleaned with water and soap, instead of alcohol-based gel because, many scientific studies findings conclude that gel sanitisers not always work depending on bacteria class and alcohol concentration percentage. HW practice among healthcare professionals has a crucial role in the prevention of HAIs. HW has been the number one defence mechanism against the spreading of microorganisms since the mid-1800s, when studies from Dr. Semmelweis, also known as the “Father of infection control”, established that HAIs were transmitted via the hands of health care professionals in Vienna, Austria (Best & Neuhauser, 2004). The Health and Safety at Work Act of 1974 and The Health and Social Care Act of 2008 are about ‘protecting workers and other persons against harm to their health, safety and welfare’. For nurses and other healthcare professionals, this includes infection control measures and means that effective HW is legally required and an essential task in the workplace. Nurses play a crucial role in the proper implementation and control of HW among clinical and non-clinical personnel because they are in constant interaction with patients. Therefore, nursing staff are required to follow the ‘My 5 Moments of Hand Hygiene’ approach introduced by the World Health Organisation in 2009 (Ramachandran, Chou & Achan, 2012). The NICE (2014) recommended that all healthcare workers should always wash their hands thoroughly, immediately before and immediately after coming into contact with a patient or carrying out care, and even after removing gloves. Nurses have the responsibility to follow their Trust’s Infection Control policies and procedures and have the responsibility of ensuring that members of the public follow procedure in reducing infections (NMC Code, 2015).HW promotion across the NHS trusts and, in a broader sense, within the healthcare sector has been consistent (NHS, 2016) in accordance to the WHO Guidelines on Hand Hygiene in Health Care: a Summary (2009) recommendations. This can be because ever since Dr. Semmelweis` discovery in the 1800s, many other studies have followed and confirmed his theory. NICE has 380 evidence-based research studies on hand hygiene effectiveness available on their system and is used to support writing today’s guidelines for infectious control and prevention for healthcare staff (NICE, 2019c). However, regardless of hand washing being widely accepted as being a low cost and key intervention for the prevention of HAIs, more current and specific clinical studies are extremely limited. Most of them look at the big picture of. hand hygiene. A 2016 study conducted over a period of 5 years in 173 NHS trust England, examined the importance of an organisational factors as part of prevention and control of MRSA infections in hospital. They concluded that improved hand hygiene, intensified cleaning and staff training on infections control helps reduce HAIs (Vera, et al., 2016). This study is not specific based on hand washing only, however, it supports another study conducted in 2010 which looked for evidence between MRSA rates and hand-washing relationship if in compliance (Nicolau Jr., et al., 2010) which strengthens the fact that hand washing is a good method for prevention and control of HAIs. For efficient care delivery, staff nurses are required to complete a hand washing exam technique while on training known as Objective Structured Clinical Examination (OSCE) before they can even register with the NMC (NHS Employers, 2018). This helps build staff competence on the topic and increase awareness about how serious the risks of cross-contamination are when not applying the correct HW technique. NHS trusts have made adequate hand washing facilities available and easily accessible in clinical areas. HW sinks are provided with liquid soap dispensers, soft paper towels and waste bins (Sunley, K. et al, 2017). Furthermore, Trusts have specialised infection prevention and control team who are usually formed by specialised nurses, that are there to reinforce ward managers and other healthcare practitioners the need for compliance of hand-washing ‘My 5 Moments of Hand Hygiene’ steps in accordance with evidence-based standards and national guidance (NHS Hampshire Hospitals Foundation Trust, 2019). These measures, when followed by healthcare professionals, have proven to be effective significantly reduces risks of HAIs within the NHS trusts and offer the public safer and cleaner hospital environments. Unfortunately, this is not always the case as randomised investigations still show that some nurses still fail to comply with the HW obligation especially late on their shifts (NHS, 2014). This is an area that still requires improvement based on three systematic reviews for the Cochrane Collaboration between 2007–2017 (Gould, 2017) reflections. There may be barriers that needs consideration when promoting handwashing. Simply introducing facilities accompanied by education can be considered insufficient as behaviour change amongst healthcare professionals has been particularly challenging (Stewardson et al, 2011). This could be because behaviour change is a complex process and implications such as; decision making on when to practice, if policy components include behavioural change strategies and available research on behaviour change interventions (Michie, et al., 2018). Another barrier could be lack of continuing educational programmes. It is well known that the NHS is under financial pressure and budgeting cuts have been made (The Independent, 2018). This means that cause trusts might not provide HW workshops to educate new skills due lack of funding, time and staff. Subsequently nurses often have very little time and there are no many key interventions behaviour change design for HW to support them on the process. The ‘Behaviour Change Wheel’ is valuable and can used to assist with the structure around HAIs prevention and control (Atkins, 2016). Having this systematically available is more likely to give nurses motivation or an opportunity for a positive change (Atkins, 2016) and therefore, possibly comply with the HW policies.Figure 1: Behaviour Change Wheel (Michie et al., 2011)Supporting the Dahlgren & Whitehead “determinants of health” 1991 model theory, which encourages the use of policies and strategies to promote behaviour changes and safer healthcare for the public. As well as, the Hawthorne effect where nurses appear to positively comply with HW activity when being direct observed, this could be through audits (Hagel et al., 2015)In UK nurses, are governed by three separate sets of legal rules which are separate from the law already established by the NHS framework. These governing bodies give them legal obligations and work ethical standards to follow under the Code of Practice (Tingle & Cribb, 2008a). The three code of practice obligations that each nurse must obey are;- Uphold and enhance the good standing and reputation of the profession- Safeguard and promote the interests of individual patients and clients- Serve the interests of society; justify public trust and confidence (NMC Code, 2015)The Nursing and Midwifery Council (NMC) Code 19.3 and 19.4 very clearly states that; it is each professional’s responsibility to “keep to and promote recommended practice in relation to controlling and preventing infection.” This includes being in compliance with hand washing practice policies in place for individual NHS Trusts. Continuous training about when, how and why to clean hands, emphasis on the derivation of their community and occupational hand hygiene behaviour patterns may support in the changing of attitudes (Squires, et al., 2013a). To help influence their workers on positive behaviour, NHS Trusts have embedded Values and Compassion of Practice as another safety management strategy with the purpose of delivering high quality care standard to the public and achieve excellence in care delivery based on its core values and behaviours recognised by carers and patients alike. These values and behaviours, with the aim to achieve a culture in any health care settings, are summarised by the 6Cs:- Care- Compassion- Competence- Communication- Courage- Commitment (Groves, 2014).These key concepts have been well-defined through extensive consultation with patients, midwives, nurses and care staff as part of a development of individuals roles and continuous behavioural improvement programs (Groves, 2014).Professor Jane Cummings, who is the Chief Nursing Officer for England, in 2014 stated that Compassion of Practice acts as a contagious condition for good practice not only to nurses but, to senior doctors, and administrative staff, on-going routine of hand washing as an institutional priority by the hospital management.In relation to nurse’s professionalism and ethics, nurses have a framework under the four principles of Beauchamp those are; respect for autonomy, beneficence, non-maleficence is an important one on this topic because nurses are reminded that they cannot intentionally create a harm or injury to their patient, either through acts of omission or commission, and last Justice (McCormick, 2013). All which play a key role in ensuring better patient safety and care. The NMC (2008) Essential Skills Clusters describes the programme that a nursing student in the United Kingdom need to undertake in order to acquire the necessary competencies to meet the criteria for NMC registration. This is a very good guideline because it prepares trainees to a realistic expectation and make each staff aware of its accountabilities if not in compliance with patient’s safeguarding and infection prevention and control policies. In 2026/17 the NHS spent £1.7 billion to cover legal costs on clinical negligence claims alone, accounting for 36 per cent of the total bill (NHS England, 2018). When nurses do not comply with the hand washing policy while at work that is exposing vulnerable patients at higher risk of HAIs, therefore, is classed as negligence. Every member of staff has the responsibility to follow their Trust’s Infection Control policies and procedures and have the responsibility of ensuring that members of the public follow procedure in reducing infections (NMC Code, 2015). the British healthcare sector has a Code of Practice used as guidance under The Health and Social Care Act of 2008 regulations, and Trusts are legally required to register with the Care Quality Commission (CQC) since April 2009 and are accountable to protect their staff, patients, and others who may be at risk of a healthcare associated infection (Weston, et al.,2016). The NHS operates under the Health and Safety at Work of 1974 Act., independent bodies such as the National Institute for Health and Clinical Excellence (NICE) and the Health Care Commission (HHC) or the Commission for Healthcare Audit and Inspection (CHAI), have been set up to promote improvement and monitor the quality of healthcare services provided to the public under the 1999 Health Act. and the Health and Social Care (Community Health and Standards) of 2003 Act. (Tilmouth and Tilmouth, 2009) although, a recent press release expressed concerns after a study revealed that 88% of the hospital staff are not in compliance with the government requirements and failing to wash their hands before and after contact with patients (Gray, 2006) despite the safety system in place. There are serious consequences when causing intentionally or unintentionally harm to patients. Nurses can be banned from practicing if reported for negligence (IBB solicitors, 2015) or even face jail time (The Independent, 2013).In conclusion, HW has proven to be one of the greatest scientific breakthroughs’ to date (WHO, 2018) by preventing the leading causes of the 5.9 million deaths that occur annually in young children around the world (World Vision, 2016). Moreover, it is one of the easiest and affordable way of reducing cross-contamination of microorganisms when in hospitals (Woodrow, 2006). Hospital acquired infections are serious issue with the NHS hospitals, however, hand washing is a procedure which has been scientifically proven to prevent and control those infections. Therefore, it should be consistently performed by all nurse in UK as part of their role. This should not optional but obligatory as per the Health and Safety 1974 Act and NMC Code of Practice. It must be used meticulously to decrease the occurrence of hospital acquired infections within the private or public healthcare sector and to increase patient safety. Not only this but an appropriate use of hand washing is also a sign of respect for the four principles of health care ethics, staff competency level and professionalism.
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