There is a wealth of evidence to suggest that hand hygiene is the single, most effective way to prevent the burden of endemic healthcare-associated infection (Allegranzi et al., 2017, Pittet et al., 2017). Patient involvement in supporting their own safety has been discussed globally (Berger et al., 2014, Prey et al., 2013, Vaismoradi et al., 2015). The question then arises as to whether patient involvement in promoting hand hygiene might be a strategy to increase hand hygiene compliance. Any policy requiring patient involvement in their safety assumes that patients are able to take an active role. There is a concern that patients may not feel able to speak up to improve the quality and safety of their healthcare (Nacioglu, 2016). Whether or not patients feel comfortable and empowered to prompt their nurse regarding hand hygiene has yet to be fully explored (Alzyood et al., 2018).
The overall aim is to understand the role of patient involvement in promoting hand hygiene among nurses in the hospital setting.
Methods:
This study was undertaken in 2 parts, focus group discussion with nurses from two countries Jordan and the UK [part 1] and interviews with patients from Jordan [part 2].
Part 1: Focus groups were conducted between August 2016 and May 2017. Each focus group had approximately 4-6 participants. Each group discussion was transcribed verbatim. Purposive sampling was applied. The sample included both male and female qualified nurses and patients from different hospital departments such as the emergency department, intensive/critical care units, dialysis units, medical/surgical wards, and maternity and paediatric specialities. In Jordan, focus groups (n=3) were undertaken in Arabic; data were transcribed into Arabic before being translated into English and verified by a native English speaker. In comparison, the focus group data from England (n=4) were transcribed directly into English. Data were imported into NVivo11© by the lead researcher to facilitate its management (Lewis, 2018). Qualitative data analysis followed the six steps of thematic analysis – developed by Braun and Clarke (2006).
Nurses were asked: Can you describe an experience when a patient reminded you to wash your hands? And how did you manage the situation?
Part 2: Interviews were conducted between June and September 2018. Each telephone interview lasted between 30-60 minutes. Purposive sampling was applied. All interviews were audio-recorded and transcribed verbatim into English by the first author [MA], before being translated into English and verified by a native English speaker. All patients participated in this part of a larger study had a hospital stay in the last five years, they were asked to describe their experience(s) or incident(s) where they did or did not ask nurses to wash their hands. Critical incident technique (CIT) using semi-structured telephone interviews used to collect data from patients (Flanagan, 1954). The interviews were performed based on an interview guide (Schluter et al., 2008) designed by the research team who are experienced clinicians working with patients and nurses. Qualitative data analysed following a descriptive critical incident analysis (Flanagan, 1954).
Patients were asked: Can you describe a situation where you asked a nurse to wash hands, or an experience when you wanted to ask a nurse to wash hands, but did not?
Results:
Part 1: Nurses who participated in this study acknowledged the problem of a lack of compliance with hand hygiene and expressed tentative agreement with the suggestion that patients could enhance compliance if they were to prompt affirming that patients have a right to ask. However, nurses also raised concerns that such prompting could affect the nurse-patient relationship and would only be acceptable if done ‘in the right way’ although they could not articulate what this ‘right way’ was.
Part 2: Many of the patients who participated in the study were reluctant to prompt handwashing; some had assumed that this should be necessary whilst others did not want to be challenging or confrontational. Their concerns were reinforced by those who had prompted handwashing; many found this to be uncomfortable and that it elicited an unfavourable reaction from the nurse.
Conclusion:
Nurses’ compliance with hand hygiene remains a threat to patient safety, and patient involvement in promoting hand hygiene compliance is a possible strategy that might increase compliance. Whilst nurses do not dismiss the concept of patient prompting, in reality, there is evidence that neither nurses nor patients find this comfortable and the strategy can come across as confrontational, damaging the nurse-patient relationship.
There were some barriers which could limit patient involvement, such as the threat to the patient-nurse relationship and the addition of more work-related stress to nursing if patients ask about hand hygiene. Some patients believe that asking is confrontational to nurses while a pleasant manner of asking could help in facilitating or accepting the reminder.
Importantly, nurses discussed possible solutions to help us shape future interventions which aim to involve patients in hand hygiene, such as promoting the culture of patients asking nurses to wash their hands, performing hand hygiene within the patient’s visual field, educating patients, and raising their awareness on the importance of hand hygiene.