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Home Healthcare Nurse:
doi: 10.1097/NHH.0b013e318246d5f4

Hand hygiene practices of home visiting community nurses: Perceptions, Compliance, Techniques, and Contextual Factors of Practice Using the World Health Organization's “Five Moments for Hand Hygiene”

Felembam, Ohood RN, BN, MAP(Hons); St. John, Winsome RN, RM, PhD, FRCNA, STTI; Shaban, Ramon Z. RN, IPN, CICP, EMT-P, PhD, FRCNA

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Author Information

Ohood Felembam, RN, BN, MAP(Hons), is a PhD Candidate at Griffith University, Gold Coast, Australia, and a Teacher Assistant at King Abdul-Aziz University, Jeddah, Saudi Arabia.

Winsome St. John, RN, RM, PhD, FRCNA, STTI, is an Associate Professor at the Population and Social Health Research Program, Griffith Health Institute, Griffith University, Gold Coast, Australia.

Ramon Z. Shaban, RN, IPN, CICP, EMT-P, PhD, FRCNA, is a Senior Research Fellow at the Research Centre for Clinical and Community Practice Innovation, Griffith Health Institute, Griffith University, Brisbane, Australia.

The authors declare no conflicts of interest.

Address for correspondence: Ohood Felembam, RN, BN, MAP(Hons) School of Nursing & Midwifery, Griffith University, Brisbane 4222, Australia (

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In this observational study, the perceptions, compliance, techniques, and contextual issues of hand hygiene practices among community clinicians (nurses) during 103 hand hygiene opportunities (based on the World Health Organization “Five Moments for Hand Hygiene”) in 40 patient care episodes were examined. Compliance with standard hand hygiene practices was generally poor, with many contextual influences making compliance difficult. Clinician preferences and convenience are important considerations in hand hygiene compliance. Improving home-visiting community clinicians' hand hygiene practices requires addressing contextual issues related to the availability of hand hygiene equipment, such as alcohol-based hand rubs, as well as hand hygiene in-service education to update knowledge on hand hygiene for everyday practice in community settings.

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This study investigated the hand hygiene practices of home visiting community clinicians. Transmission of healthcare-associated infections (HCAIs) is a significant risk wherever healthcare is provided. Hand hygiene is the most effective preventative measure to reduce this risk. Much of the existing research examines hand hygiene practices in hospitals, and little is known about clinicians' practices in community settings, particularly since the introduction of the “Five Moments for Hand Hygiene” concept by the World Health Organization (WHO; 2009a) (Table 1). This concept aims to protect patients against acquiring infectious agents from the hands of the healthcare workers, prevent pathogens from entering the patient's body during procedures, maintain a safe healthcare environment, and prevent healthcare workers from acquiring infectious agents from patients. The “Five Moments for Hand Hygiene” divides the healthcare setting into two zones: the patient zone and the healthcare zone. The patient zone is marked out as the patients' skin and their immediate surroundings, whereas the healthcare zone is defined as all other surfaces that are not colonized by patient flora. The “Five Moments for Hand Hygiene” are as follows: Moment 1, before touching the patient; Moment 2, before starting any invasive medical procedure or aseptic procedure for the patient; Moment 3, after contact with body fluids or excretions, mucous membranes, nonintact skin, or after any procedure such as wound dressings; Moment 4, after touching the patient; and Moment 5, after contact with surfaces and objects in the patient's surroundings. In addition, cough etiquette is recommended when coughing or sneezing. The mouth and nose are covered with the hands to prevent respiratory secretions spreading into the air, then hand hygiene is practiced immediately after contact with respiratory secretions.

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Table 1
Table 1
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Infection Control in the Community

Infection control is essential for quality and safety in healthcare (National Health and Medical Research Council [NHMRC], 2010). Prevention of HCAIs is central to these efforts (Embil et al., 2009), particularly during high-risk procedures, such as surgery, parenteral therapy, wound care, and catheterization. The hospital has been the traditional setting for formal healthcare. However, in the late 20th century, there has been a concerted effort to relocate healthcare from hospitals into community settings (Kralik et al., 2008). As it becomes more common for patients to be sent home with central lines, nasogastric tubes, catheters, and intravenous medication for management by patients, family members, and visiting health professionals, so too does the risk of HCAIs. The emergence of new community-acquired infections, particularly those associated with multidrug resistance organisms, makes providing safe, high-quality healthcare in community settings more challenging (Zetola et al., 2005).

Hand hygiene is the single greatest infection prevention and control strategy (Jumaa, 2005). Although hand hygiene is a clear mandate for all clinicians, clinicians in community settings may encounter challenges in maintaining hand hygiene practices that are not faced by their hospital-based colleagues (Nazarko, 2009). These include environmental and resource challenges and the limited facilities available in patients' homes for hand hygiene.

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Hand Hygiene Compliance

Healthcare workers' compliance with hand hygiene standards has been shown to be generally poor (Carroll, 2001; Jumaa, 2005; Kampf, 2003; Kenneley, 2007; Nazarko, 2009; Pittet, 2000). Suggested reasons for lack of compliance in community settings are poor accessibility and availability of hand hygiene equipment (Bennett & Mansell, 2004; Caroll, 2001; Gould et al., 2000; Kenny, 2002; Nakano et al., 2002). The use of alcohol rubs for routine hand hygiene when hands are not visibly soiled is established best practice (Bisset, 2002; Boyes & Pittet 2002; Picheansathian, 2004; Trampuz & Widmer, 2004), yet little is known about hand hygiene practices and behavior in community settings, particularly since the WHO introduced the concept of the “Five Moments for Hand Hygiene” in 2009. No published studies were located that examined community nurse clinicians' current hand hygiene techniques and compliance according to the “Five Moments for Hand Hygiene” concept, the influence of alcohol rubs availability, or the contextual barriers to community clinicians maintaining adequate hand hygiene standards.

There is considerable literature on the factors that influence hand hygiene practices generally, particularly in formal hospital settings. Firstly, intact skin is a natural defense against infections (Marieb & Hoehn, 2007). Cuts and abrasions are a breach of this natural defense, and may complicate hand hygiene practices as they could be a source of entry for infections. Therefore, it is important to cover cuts and abrasions with a waterproof dressing. Fingernails are another issue and should be kept short and clean. Artificial nails should not be worn when providing clinical care, because they are associated with high levels of infectious agents. Moreover, jewelry should be limited to plain bands such as wedding rings; however, these should be removed from fingers during hand hygiene practices because wearing rings increases contamination with infections. Finally, hand cream should be applied regularly. Taking care of hands is important as hand hygiene products may irritate and dry the skin. Many studies have stressed the impact of practicing good hand hygiene in reducing HCAIs. Despite overwhelming evidence supporting hand hygiene practices, compliance is generally poor with an overall average of 50% for health workers (Carroll, 2001). However, knowledge about enablers and barriers to effective hand hygiene practices in hospital-based settings may not accurately reflect challenges that are present in the community context.

The aim of this study was to investigate the hand hygiene practices of home visiting community nurses to determine consistency of practice with contemporary standards for hand hygiene, explore nurses' perceptions on hand hygiene, and to identify contextual factors that influence hand hygiene practice in the field.

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Study Setting

The present study examined the hand hygiene practices of home visiting community nurses from two not-for-profit home healthcare agencies (HHAs) located in Queensland, Australia. Both agencies provided a range of health services to clients, including wound care and dressings, palliative care, medication preparation and administration, assistance with activities of daily living (e.g., showering), and vital signs monitoring (e.g., blood pressure and glucose measurement). Both agencies were reviewing their hand hygiene policies and provided staff with alcohol-based hand rub.

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Study Design

Direct observation is considered the gold standard for research into hand hygiene practices (Boyce, 2008). However, observations have been seldom used in previous community-based studies of hand hygiene, which typically use self-report and survey data collection methods. In this study, direct field observation methods were used to review current hand hygiene practices and compliance with contemporary standards of hand hygiene practices, and to assess barriers and enablers to hand hygiene compliance in a community setting. A brief questionnaire was also used to collect demographic information and explore clinicians' perspectives on hand hygiene. For the purpose of this study, assessment of clinicians' hand hygiene compliance incorporated assessment of their adherence and technique. Adherence is the extent to which clinicians' performed hand hygiene when indicated in accordance with the “Five Moments for Hand Hygiene.” Assessment of hand hygiene technique relates to participants' actions and procedures during each hand hygiene episode.

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Sample and Recruitment Process

The researchers' university Human Research Ethics Committee and the participating HHAs provided approval to carry out the study. A purposive sample of home visiting community nurses was recruited from the two HHAs. A meeting was held with clinicians from each agency to outline the purpose, benefit, and risks of participating in the study. Inclusion criteria were that the clinician participants were between the ages of 20 to 65 years, were working full-time or part-time as a home healthcare community clinician; had more than 5 years of nursing experience and no specialist expertise in infection control. Eight nurses were recruited to the study from the two HHAs.

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Data Collection

A total of eight home healthcare nurses participated in the study between March and June 2010. Each participant was accompanied on their home care visits for 1 day from approximately 9:00 am to 3:00 pm, visiting approximately four to six clients per day, for a total of 33 client visits. All visits were to clients' homes, except 1 visit to a community center to provide services for homeless people. The length of client sessions was approximately 30 minutes but varied according to the services being provided. The total observation time was approximately 16 hours (952 minutes). There was a total of 103 hand hygiene opportunities performed by eight different nurses during 33 client visits while performing 40 client care episodes.

Two tools were used for data collection: the Hand Hygiene Observation Tool-Modified (HHOT-M) and the Community Healthcare Hand Hygiene Audit-Modified (CH-HHA-M). HHOT-M is based on the WHO's Hand Hygiene Observation Tool of “Five Moments for Hand Hygiene” (WHO, 2009b), for which validity has been tested for applicability and adaptability (Sax et al., 2007). HHOT-M was used to collect data about the physical surroundings, accessibility of equipment, and availability of hand hygiene facilities in patients' homes. The tool included a checklist of hand hygiene resources such as alcohol rub, soap, hand cream, and paper towels. Assessment of compliance with hand hygiene techniques included recording the type of hand hygiene action performed (handwashing and hand rubbing with alcohol rub) at the appropriate opportunity as well as hand hygiene steps (e.g., removing jewelry, washing, rubbing all surfaces, and drying). The researcher assessed the physical surroundings and marked (✓) the available resources in the environment related to hand hygiene.

The CH-HHA-M was researcher-administered and explored participants' perceptions on hand hygiene. The questions identified participants' preferences for hand hygiene method, their reported hand hygiene practices, and their last hand hygiene education update. Demographic information about age, gender, years of experience, and qualifications was also collected.

The researcher used a notebook to document any additional observations, activity, or events that had the potential to affect the clinician's hand hygiene practices. Supplies provided by the client and orgnization were documented. Supplies provided by clients included soap, paper towels, clean or used towels, and hand moisturiser; organizationsal supplies included gloves, gowns, alcohol-based hand rub, and dressing kits.

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Data Analysis

Descriptive statistics were used to describe the sample. Observational and questionnaire data were analyzed using frequencies, mean, median, standard deviation, minimum, and maximum. Hand hygiene adherance and techniques in relation to the “Five Moments for Hand Hygiene” were calculated according to the WHO calculation equation (WHO, 2009b).

Observational field note data were analyzed by matching them to the appropriate section of the data collection tool (HHOT-M) or questionnaire (CH-HHA-M). For example, additional data collected in field notes on hand hygiene resources were matched with the hand hygiene resources available section of the HHOT-M.

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The majority of the participants (n = 5) were 41–60 years old, and most (n = 6) were female. Half of the participants (n = 4) had between 20 and 39 years of experience (SD = 1.458, M = 2.88). Most participants (n = 6) were hospital-trained for their initial nursing education, with two having a bachelor's degree and one a master's degree as their highest qualification.

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Hand Hygiene Practices of Community Clinicians Providing Home Healthcare

Sixty-one hand hygiene actions were performed during 103 hand hygiene opportunities. Handwashing with soap and water was the most performed action at 44 times, followed by the use of alcohol rubs, which was used 17 times. Participants' adherence at appropriate opportunities is summarized in Table 2. Individual adherence ranged between 36.4% and 86.4%, and the mean rate was 59.2%, which is considered poor. The most practiced was Moment 3, which is after exposure to body fluid or after performing an aseptic procedure (Table 3). The least practised was Moment 5, which is after touching the patient's surroundings.

Table 2
Table 2
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Table 3
Table 3
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Table 4 presents participants' techniques for each moment of hand hygiene. Despite poor adherence to the “Five Moments for Hand Hygiene,” analysis revealed that participants mostly practiced appropriate hand hygiene techniques (Table 4). During the 44 handwashing events, the most commonly performed measures were wetting hands thoroughly, use of soap, lathering vigorously, and rinsing under running water. Turning off taps with paper towels was the measure that was performed the least. Half of the participants (50%) wore a wedding ring or more than one ring on their fingers and did not remove them before performing hand hygiene. During hand rubbing events, participants covered all hand surfaces with alcohol rub solution 13 times (21.3%) and rubbed their hands vigorously with the solution 8 times (13.1%). Applying hand rub solution and rubbing hands until the solution dried was performed 17 times (27.9%). The measure participants failed to do most often for both handwashing and alcohol rubs was to vigorously rub or lather their hands.

Table 4
Table 4
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Influences on Community Clinicians' Hand Hygiene Practices in the Field

Table 4 summarizes the resources that were available to the participants during their client visits. Observations showed that participants' hand hygiene practices were influenced by resource availability and knowledge about hand hygiene practices. While all participants had ready access to alcohol rubs, some participants kept them in the car and did not take them into clients' houses. One participant identified that holding a bottle when visiting a client's house was bothersome and that it could be left behind accidentally. Most clients, 87.5%, provided plain or antimicrobial liquid soap and 37.5% provided a bar of soap. Paper towels were available in one client's house and other clients provided either a clean or a used towel. The most common tool for drying provided by clients was a used home towel (62.5%), followed by a clean home towel (50%). Paper towels were the least provided drying tool (12.5%). Soap and drying facilities were not available in one client's house or at the community centre.

Gloves were available most of the time (62.5% of visits), and used by some participants occasionally. Participants neither took lotions and moisturizers with them, nor did clients provide them. Six participants reported that they never used lotions or moisturizers, because they never felt the need to use them. Two clinicians thought that the greasy feeling of hand moisturizers was inconvenient and could build up dirt on their hands. One participant reported having dermatitis from using hand hygiene products.

Participants' self-reported knowledge about hand hygiene is summarized in Table 5. Participants reported that their knowledge on hand hygiene was often not updated. Two participants had received an educational update in the previous year and reported understanding the concept of the “Five Moments for Hand Hygiene”; however, only one of the participants followed the concept. Six participants preferred handwashing to alcohol rubs, reporting that they washed their hands when they were visibly soiled or after removing gloves, because they considered handwashing more effective than alcohol rubs in removing microorganisms from their hands.

Table 5
Table 5
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A key observational finding was that personal safety considerations influenced hand hygiene practices. For example, when working with homeless clients, participants had no access to hand hygiene facilities to wash their hands. Rather than risk walking alone to reach public facilities to wash their hands, they used alcohol rubs.

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Findings showed that home healthcare clinician participants' hand hygiene practices were not consistent with contemporary hand hygiene standards or infection prevention and control guidelines (National Institute for Health and Clinical Excellence, 2003; NHMRC, 2010). Although alcohol rubs are currently recommended as a standard for routine hand hygiene because they are the most convenient, effective, and time efficient measure (Pittet et al., 2004; Trampuz & Widmer, 2004), these participants often washed their hands rather than using alcohol rubs.

Participants' adherence at the hand hygiene moments varied. Their adherence at Moment 1, 2, and 3 is expected, as it is logical to clean hands before touching a patient, after exposure to body fluids, or before performing an aseptic procedure. However, participants sometimes missed hand hygiene practices at Moment 2 and also Movement 5. Their lower adherence at Moments 2, 4, and 5 may, perhaps, be the result of working with one client at a time in a discrete environment. However, clinicians in a community setting cannot presume that the patient's environment is clean, especially when the next procedure is wound dressing. There are no published studies of community clinicians' hand hygiene practices with which to compare the findings of this study. However, participants' adherence can be compared to the findings of Whitby et al. (2006), who concluded that clinicians' hand hygiene adherence at Moment 3 (after contact with body fluid or performing an aseptic procedure) can be considered inherent and adherence at Moment 5 (after touching the patient's surroundings) can be categorized as elective.

With regard to enablers and barriers, the convenience of hand hygiene facilities, equipment, and supplies, particularly alcohol rubs appears to be a problem in the community context. The use of alcohol rubs among these home healthcare clinicians was poor. Participants were provided with alcohol rubs by their agencies, which is consistent with hospital-based settings (Pittet et al., 2004; Trampuz & Widmer, 2004); however, accessibility and convenience seemed to be an issue. The type of drying tools clients provided included used home towels, clean home towels, and paper towels, which is similar to the findings of Gould et al. (2000) that towels were sometimes not provided or were too soiled to be used. Participants used gloves less often than found in the study of Nakano et al. (2002), where gloves were provided by agencies and glove usage was 82.6%. However, while using gloves is a part of hand hygiene practices, they are not necessary for the “Five Moments for Hand Hygiene.” It was striking that lotions and moisturizers were not used or popular with participants in this study. Clients did not provide them, nor did participants access them from their agency or supply their own. Dermatitis was not found to be a major issue in our study, which is different from the findings of previous studies (Bennett & Mansell, 2004; Bisset, 2002; Carroll, 2001; Gould, 2000; Kampf, 2003; Nazarko, 2009; Pellowe, 2006; Pittet, 2000; Smith, 2009; Trampuz & Widmer, 2004; Ward, 2002), suggesting that skin irritation is a major factor for poor compliance with hand hygiene. An interesting observation was that clinician safety had an impact on hand hygiene choices. Where safety and convenience was an issue, clinicians used alcohol rubs, even though these were not preferred.

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Findings of this study show that clinician preferences and convenience are an important consideration in hand hygiene compliance. The participants preferred and used handwashing with soap and water rather than alcohol rubs, which is not consistent with the global standard recommending alcohol rubs for routine hand hygiene practices (WHO, 2009a). Ready availability of alcohol rubs may encourage better hand hygiene practices, especially when resources are not offered or available in the home. Review of available hand hygiene products for suitability, acceptability, convenience, and applicability to the community context may improve compliance. For example, to make access and disposal of alcohol rubs easier, they could be provided in small-quantity disposable containers such as sachets, or via use of a belt clip. Alcohol rub sachets could be included in disposable wound dressing kits. Clinicians could be provided with disposable hand hygiene kits that include sachets of liquid soap, alcohol rub, disposable alcohol wipes, and paper towels.

The findings of the present study suggest that clinicians' knowledge of appropriate hand hygiene was not contemporary, as few participants had attended recent hand hygiene education or knew of the WHO “Five Moments for Hand Hygiene,” established in 2009. Ward (2002) stated that a lack of education on hand hygiene was one of the barriers to compliance with hand hygiene practices. Our study suggests that continuous in-service education is a vital element for achieving better hand hygiene practices.

Although direct observation is regarded as the ideal method for examining hand hygiene practices, there are limitations, such as the Hawthorne effect. Despite the Hawthorne effect and participants knowing that their hand hygiene practices are being examined, observation is a powerful tool for examining adherence and techniques in the field. It is arguable that hand hygiene practices may actually be less compliant than found in this study. Although only eight home healthcare clinicians from two HHAs participated, and this study was limited to a region in Australia, findings could inform studies in other community healthcare settings. Future research could investigate hand hygiene practices with larger samples in a broader range of community contexts, the applicability of the “Five Moments for Hand Hygiene” in the community context, and explore the use of alcohol rub, hand care, and clinician preferences.

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The hand hygiene practices of community nurses were not consistent with best practice. Availability of, access to, and convenience of hand hygiene resources continue to be barriers to compliance in a community setting. The use of alcohol rubs, which is considered best practice as per current hand hygiene guidelines (National Institue for Health and Clinical Excellence, 2003; NHMRC, 2010), was poor. Review of the appropriateness, accessibility, and convenience of hand hygiene resources and ongoing in-service education is needed to improve community clinicians' hand hygiene practices in a community setting.

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