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SYSTEMATIC REVIEWS

Patient experiences of partnering with healthcare professionals for hand hygiene compliance

a systematic review

Butenko, Samantha1,2; Lockwood, Craig1; McArthur, Alexa1

Author Information
JBI Database of Systematic Reviews and Implementation Reports: June 2017 - Volume 15 - Issue 6 - p 1645-1670
doi: 10.11124/JBISRIR-2016-003001
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Abstract

ConQual summary of findings1

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Figure

Background

Healthcare-associated infections (HAIs) cause patient morbidity and mortality and are associated with significant human and financial costs.2 There are around 200,000 HAIs in Australian acute healthcare facilities each year.2 This makes HAIs the most common complication affecting patients in hospital. In addition to causing unnecessary pain and suffering for patients and their families, these adverse events prolong hospital stays and are costly to the health system.2

Transmission of infectious organisms occurs in a number of ways, including by contact (direct and indirect), droplet, airborne and vector-borne routes.2 It is important for healthcare professionals and patients to understand how organisms are spread and to have an understanding of how to minimize the risks associated with the spread of infectious organisms in the healthcare setting.2

In healthcare settings, those most susceptible to the risk of infection are patients and healthcare professionals. Infections can result from external factors (exogenous infection) and/or factors directly related to the patient themselves (endogenous infection).2 Infection prevention and control risk minimization strategies aimed at reducing the incidence of HAI involve both human/behavioral and organizational system-based actions.2 Infection prevention and control is ultimately about people and is an essential element of the provision of high-quality patient-centered care.2

Organization-based systems, such as infection prevention and control programs, include activities aimed at the prevention of the transmission of infectious agents and the minimization of the risk of HAIs.2 Programs include the implementation of standard and transmission-based precautions. Standard precautions are defined as work practices aimed at minimizing the risk of transmission of infection (predominantly via blood/body fluids via contact) and apply to the care of all patients, regardless of their known or perceived infection risk. Transmission-based precautions (formally known as additional precautions) are implemented when standard precautions alone may be insufficient to interrupt the transmission of infectious agents (predominantly used for contact, droplet and airborne transmission and significant organisms), and these precautions are tailored to the specific mode of transmission of the infectious organisms.2

Hands can play a role in the incidence of infection and the spread of micro-organisms, as infectious agents can be transmitted by touch.2 Micro-organisms can be present on hands as part of resident flora (present on the skin) or transient flora (organisms picked up or acquired).2 Hand hygiene is considered to be one of the most important infection control actions to help minimize the risk of infection. Improved hand hygiene practices have been associated with sustained decreases in the incidence of infections caused by multi-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus, reductions in HAIs of up to 45% in a range of healthcare settings and also greater than 50% reductions in the rates of nosocomial disease associated with MRSA, and other multi-resistant organisms after one to two years.2

According to the Hand Hygiene Australia data, as of October 2013, the overall Australian hand hygiene compliance rate was 79% (data collected nationally from a total of 752 hospitals from both the public and private sectors).3 There was variation within the healthcare professional groups, with nurse/midwives at 82.9% and medical practitioners 65.8%. Significantly, overall compliance rates indicated a lower hand hygiene compliance rate before touching a patient (74.9%), in comparison with the rate for after touching a patient (84.4%).3 When reviewing the data, it appeared that healthcare staff had a greater focus on self-protective behaviors, given the higher level of hand hygiene compliance after touching a patient than before touching a patient.

These trends are also reflected in international literature. Data from the World Health Organization (WHO) have found that healthcare professionals’ compliance with hand hygiene ranges from 5% to 89%, with an overall average of 38.7%.4 When interpreting these data, it should be noted that within these figures are different compliance rates among the different disciplines as well as variations in data collection methods. However, risk factors for poor adherence with hand hygiene practices have included being a doctor or nursing assistant rather than a nurse; however variance amongst different specialties has been noted. Other barriers to compliance have included skin irritation from hand hygiene products, inaccessible supplies, interference with the healthcare professional and patient relationships, patients’ needs coming before hand hygiene, wearing of gloves, forgetfulness, lack of knowledge, insufficient time, high workload and understaffing.4

Strategies to minimize the risks encountered by patients in healthcare settings, including those related to HAIs, include key guidelines that outline strategies and core care criteria.2,4,5 Within Australia, the Australian Commission on Safety and Quality in Health Care developed the National Standards for Safety and Quality in Healthcare Standards (NSQHS), with specifically Standard Three that relates to the prevention and controlling of HAIs. In addition, Standard Two of the NSQHS relates to partnering with consumers.5

Within healthcare, there is a movement and perhaps an expectation that patients should partner and be involved in their own care, including identifying and reducing risks relating to hand hygiene.2,4 Hand hygiene programs can include strategies that encourage patients to speak up regarding healthcare professional non-compliance with hand hygiene.2,4 The patients’ experiences appear to differ, with some patients appearing to feel disempowered and reluctant to speak up for fear of retribution from healthcare professionals.4

Patient involvement in their healthcare has progressed during recent times, and the patient's role in their care and safety continues to evolve.2,4 Patient empowerment and partnering in the healthcare setting has expanded into the realm of patient safety, including hand hygiene practices by healthcare professionals.4 The term “empowerment” has different meanings, but generally involves the process of an individual or community gaining knowledge, skill and attitudes to enable them to make and be part of choices relating to their care. It is considered necessary for patients to be empowered so as to participate in their care.4 Patient empowerment involves a number of factors including self-interest and motivation as well as demographic factors such as age, culture, background, personality and intelligence.4

There appears to be no set definition on what partnering with patients means; however, it is often considered a general concept that involves patients’ empowerment, and patients participating and having input into their own care.4 There was a wide variation in terms used in the published literature identified, though the comprehensive search for this systematic review indicates the inclusion of patients in their care. Terms used to describe the patient partnership with healthcare activities and healthcare professionals included patient participation, consumer participation, patient-centeredness, patient empowerment, patient partnership, patient safety practice (PSPs) and patient engagement.2-4

Similarly, interventions aimed at promoting partnership had quite differing approaches, ranging from relatively passive interventions, such as videos and posters, to education campaigns, to active partnerships, where patients were encouraged and expected to actively monitor and intervene in breaches of practice by their healthcare professionals.4 Patients were encouraged to speak up regarding breaches in infection control practice, including missed episodes for hand hygiene by healthcare professionals.4 Hand hygiene was considered a relatively visible breach in practice that patients were able to witness directly.

Programs for patient and staff empowerment in the context of hand hygiene improvement can be categorized into educational (including Internet), motivational (reminders/posters) and role modeling within the context of a multi-modal approach.4 Internationally, hand hygiene programs such as the WHO SAVE LIVES: Clean Your Hands program have tips for patients to encourage healthcare professionals to undertake hand hygiene.4

The WHO hand hygiene program includes the provision of tips for patients regarding how to have positive interactions with healthcare professionals about their care. The tips included promoting that patients encourage healthcare professionals to perform hand hygiene by reminding or thanking healthcare professional staff with regard to their hand hygiene practices and compliance.6 The tips and advice provided to patients were in part based on an assumption that the experience of partnering and reminding staff to perform hand hygiene would be a positive interaction and experience, with a shared objective to avoid infection.

There is evidence that a patient's ability or motivation to partner with healthcare professionals for hand hygiene compliance is influenced by numerous factors.2,4 Factors influencing partnering included health literacy, socio-economic status, education level, gender, previous health experience, level of perceived or actual empowerment and demonstrated openness of the healthcare professional to be prompted by patients.4

Significantly, while there are a number of quantitative systematic reviews that have explored the effectiveness of either promoting engagement with patients in selected safety initiatives (including medication safety, cardiac rehabilitation programs, hand hygiene, anticoagulation therapy, falls prevention, etc.), there is limited qualitative data relating to the patient and healthcare professional experience participating in the various initiatives.

Patient engagement is purported to be integral to a patient-centered approach to health care and an important component of patient safety. Promotion of the patient's engagement as a means to reduce adverse events in the acute care setting was explored in a review by Berger et al.7 The review investigated the interventions aimed at improving patient safety by increasing patient involvement in certain safety actions including staff hand hygiene. The review focused on the effectiveness of the PSPs and provided comprehensive quantitative data. The review concluded that although patient engagement is an appealing concept, there is a lack of high-level evidence regarding its implementation.7 The review identified that to understand the complex behavioral and cultural aspects of partnering for hand hygiene, it was necessary to understand the phenomenon of patient or healthcare professional experiences relating to hand hygiene compliance.

Patients are uniquely placed as observers of health care as they are physically present at every encounter and have a high level of vested interest in the process of care and the eventual outcomes.7 While it appears that patients indicated a willingness to partner in their care, including specifically hand hygiene, there was a disconnect between the intention and the actual act of asking a healthcare professional if they had performed hand hygiene or not. The emerging themes regarding the patient's experience relating to partnering with healthcare professionals for hand hygiene compliance related to behavioral and cultural issues as well as beliefs and attitudes.

In a systematic review by Schwappach,8 it was noted that patients shared a positive attitude about engaging in their safety at a general level, but their intentions and actual partnership behaviors varied considerably. The Schwappach review proposed that patients were potential effective partners in their care as they were present during healthcare interventions, such as medication administration and hand hygiene. The review also indicated that partnering between the patient and the healthcare professional required bi-directional communication. Bi-directional communication was described as asking questions and informing providers about experiences, occurrences and observations.8 The review also highlighted that while patients were concerned about their care and could identify adverse events, this concern did not always result in engaging or partnering with healthcare professionals. There was a concern that patients might feel that the responsibility of ensuring their safety was being disproportionally shifted from the healthcare professional to the patient.8

Traditionally, the responsibility of patient's safety was situated predominantly with healthcare professionals and patients were passive recipients of care.9 However, as patients today have greater access to information and increasing expectations regarding the safety and quality of care, there appears to be a movement advocating shared responsibility for healthcare safety. This shift in traditionally held roles, cultures and beliefs not only provide opportunities but also challenges. In a paper by Lawton and Armitage,9 the UK campaign Clean Your Hands was cited as an example of a campaign that involved patients in hand hygiene. As part of this campaign, patients were encouraged to question staff about their hand hygiene practice. Quantitative evidence indicated that although hand gel usage increased and infections reduced, there was a reluctance to question staff by 57% of patients. Significantly, the role of being either a patient or a healthcare professional is not mutually exclusive, and thus a healthcare professional can find themselves in the patient's role. Lawton and Armitage9 reported anecdotal evidence that when a healthcare professional becomes a patient, they experience a sense of unease about challenging those providing their care, despite an awareness that something was wrong.

Patients have differing levels of comfort in asking healthcare professionals to perform hand hygiene, and they consider the type of healthcare professional when making the decision to challenge or speak up for hand hygiene compliance by their healthcare professional.4 Patients are in the unique position of being present at each part of the healthcare encounter as opposed to healthcare professionals who rotate the care of many patients. The consistent presence of the patient could then place them in an important position to be aware of and possibly speak up regarding errors such as missed moments for hand hygiene.7 However, despite being first-hand witnesses to the healthcare being provided, patients encounter barriers to partnering and speaking up stemming from their own personal beliefs and confidence as well as inhibitors from external factors such as lack of provision of education or invitation to partner with healthcare professionals.4,7

In a study by McGuckin et al.,10 patients indicated a willingness to be empowered, with 60% of patients in the study indicating that they were comfortable asking healthcare professionals if they had washed their hands. Significantly, there was a variation in which particular healthcare professional's patients actually asked, with patients asking physicians 40% of the time versus 95% of the time for asking a nurse.10

One of the basic mantras of healthcare professionals is to do no harm, and infection prevention and control guidelines aim at preventing harm that arises from HAIs.2,4,5 Patients may not always have easy access to formal infection control guidelines and standards; however, access to popular media, such as newspapers, provides patients with relatively easy access and information relating to the issues and risks of HAIs. With this increasing patient's awareness of risk, healthcare professionals may potentially face potential medicolegal challenges relating to informed patients undertaking litigation and seeking damages associated with missed hand hygiene and HAIs. In a recent article in the Sydney Morning Herald, Unwashed Hands put Doctors in Legal Peril,11 it was reported that a clear link between hand hygiene behavior and the incidence of infection with a cross association was needed, with successful litigation linked to hygiene.11

The experience of partnering with patients for hand hygiene compliance by healthcare professionals may have other strong drivers of behavior that differ from those of the patient. Patients may see partnering in hand hygiene compliance as a measure to improve their safety and health outcomes, whereas healthcare professionals, while ultimately valuing patient safety and other drivers of behavior, may also consider the risk of litigation as an influencing factor in their hand hygiene compliance.

Historical accounts indicate that the healthcare professionals’ varied experiences and compliance with hand hygiene are not a new phenomenon. Reports from the 1840s provide accounts of the work of Dr Ignaz Semmelweis, a Hungarian physician who proposed that improving hand hygiene practices could drastically reduce the number of women dying after childbirth.12 Despite Semmelweis providing his evidence to the medical elite of the time, his views were not considered part of the medical beliefs of the time and he was dismissed from his position and committed to an asylum.12

There appears to be many influences of patient safety including hand hygiene behavior and the interactions between patients and healthcare professionals. The patient and healthcare professional's experience, in relation to partnering for hand hygiene compliance, is a multi-factorial issue. There appears to be a number of common goals regarding hand hygiene compliance including the prevention of infection. However, there appears to be differing considerations, drivers, attitudes, intentions, actions and emotions, unique to patients and healthcare professionals, that influence the behaviors of the patient, the healthcare professional and the overall experience of partnering for hand hygiene compliance. It could be proposed that although patients have a positive attitude about engaging in their safety in the healthcare setting, their experiences, intentions and actual behaviors vary considerably. It appears that patients are less likely to engage in behaviors that require questioning of medical authority.8 A patient's intention to act and engage, and the subsequent undertaking of the action of engagement or partnering with healthcare professionals, seems to be influenced by personal, internal and external factors; social, cultural and behavioral norms; and systematic and structural factors.

The rationale for conducting this systematic review was to critically appraise the best available evidence relating to the patient and healthcare professionals’ experiences of partnering for hand hygiene compliance in the acute adult healthcare setting. In addition, the review sought to understand the social meaning, culture, drivers of behavior and rituals relating to hand hygiene compliance. The research sought to describe the patient's and healthcare professional's experience relating to patients speaking up and challenging healthcare professionals in hand hygiene compliance. This study was conducted to provide evidence to both patients and healthcare professionals and to inform implications for practice and research, with the ultimate aim to improve patient care. At the time of submission for publication, there were no identified protocols or completed published systematic reviews available on this topic. This systematic review was based upon an a prioiri protocol that had been subject to blinded peer review and subsequently published in the JBI Database of Systematic Reviews and Implementation Reports.13

Objectives

The objective of this systematic review was to determine the best available evidence in relation to the experiences of patient of partnering with healthcare professionals with hand hygiene compliance.

Inclusion criteria

Types of participants

The current review considered qualitative (critical or interpretive) papers that included adult in-patients and healthcare professionals (doctors and nurses) in the acute hospital care setting. Adult was considered to be any person aged 18 years or over. It should be noted that consumers in this context were patients and vice versa; the term patient is therefore used throughout this report for consistency.

Types of intervention(s)/phenomena of interest

The current review considered studies that investigated experiences of partnership between patients and healthcare professionals (doctors and nurses) in relation to hand hygiene compliance. Specifically, this review investigated the phenomena of partnering from both the perspective of the patient and the healthcare professional.

Types of studies

The review considered studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research. As qualitative studies were identified and on appraisal found to be of sufficient quality for inclusion, this review did not seek alternate forms of evidence such as text and opinion.

Search strategy

The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. An initial limited search of MEDLINE and CINAHL was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Third, the reference list of all identified reports and articles was searched for additional studies. Studies published in English language were considered for inclusion in this review. Studies published from 1990 to May 2015 were considered for inclusion in this review as this time period saw the rise of published, accessible research related to partnering as a construct within the healthcare sector (refer to Appendix I).

The databases searched included PubMed, CINAHL and PsycINFO.

The search for unpublished studies included Google Scholar and SALUS for gray literature, as well as a Google search that identified newspaper articles (Sydney Morning Herald) and blogs (Crickey) based upon the free text keywords as described below.

Initial keywords used were: hand hygiene, compliance, patient participation, empowerment, patient engagement, patient centeredness, partnership, patient safety practices, health literacy, healthcare professional and healthcare worker.

Method of the review

Qualitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment, Review and Appraisal Instruments (JBI-QARI).14 Any disagreements that arose between the reviewers were resolved through discussion or with a third reviewer.

Data extraction

Qualitative data were extracted from papers included in the review using the standardized data extraction tool from JBI-QARI.14

Data synthesis

Qualitative research findings were pooled using JBI-QARI.14 This involved the aggregation or synthesis of findings to generate a set of statements (categories) that represented aggregation, through assembling the findings rated according to their quality, and categorizing these findings on the basis of similarity in meaning. These categories were then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice.

Results

The systematic search of bibliographic databases, gray literature and reference searching returned 266 citations. Refer to Table 1 for the number of studies found and retrieved. A total of eight duplicate citations were identified and removed. The remaining title and abstracts were screened for eligibility against the inclusion criteria of the review, following which 253 were excluded as they did not meet the inclusion criteria.

Table 1
Table 1:
Number of studies found and retrieved

Five papers were retrieved for critical appraisal. On detailed reading, there were three studies that were included in the review for data extraction and synthesis of findings (refer to Appendix II for details of the included studies).16-18 Two papers did not meet the inclusion criteria, and these were therefore not extracted. Refer to Appendix III for the excluded studies. The data extracted included specific details about the interventions, populations, study methods and phenomena of interest to the review question and objectives (Appendix IV). The process of searching, screening, inclusion and exclusion of papers is reflected in the PRISMA flowchart (Figure 1).

Figure 1
Figure 1:
PRISMA flowchart of the study selection and inclusion process15

Description of studies

The three included studies for final data extraction and synthesis are reported (Table 2) with included study details reported in Appendix II.

Table 2
Table 2:
JBI-QARI number of studies included and excluded

The publication dates of the included studies ranged from 2009 to 2015. Studies included healthcare professionals (doctors and nurses) as well as adult in-patients from English speaking acute hospital settings. The studies included were geographically located in the United States of America,16 the United Kingdom17 and Australia.18

Methodological quality

The methods of data extraction used in the three included papers included semi-structured interviews and video reflexive ethnography. The semi-structured interviews involved a brief structure list of questions designed to prompt the researcher to discuss key issues. Interviews were audio recorded and transcribed as well as field notes taken.16,17 Video reflexive ethnography was utilized in one of the included studies.18 This research methodology involved 300 hours of fieldwork involving ethnographic observations including video footage, which was then shown back to patients in a one-on-one reflexive session. The reflexive session involved the patient and the researcher viewing the video footage and having unstructured discussions to encourage open dialog and reflections of not only the activities of the healthcare professionals but also the patient's own beliefs and behaviors.18

Although only one study had a clearly stated alignment between the methodology and philosophical perspective, all studies demonstrated congruity between methodology and question, methods, analysis and presentation of the data.18 There was generally low reporting locating the researcher either culturally or theoretically and equally low reporting of the role of the researcher in terms of potential impact on the research; overall, these studies were considered to be of high quality. The methods of data collection and a summary of participant characteristics are reported below. The two excluded studies were not excluded on the basis of methodological quality; however, in examining their methods and methodology in the detail required for critical appraisal, it became apparent that they were not congruent with the inclusion criteria.

The methodology for the Seibert et al.16 study was not stated; however, it appeared to be a qualitative descriptive study. The study utilized semi-structured interviews, audio recordings and verbatim-transcribed responses. The aim of the study was to explore barriers to recommended practices that promote a safe healthcare environment, including hand hygiene. There were 42 study participants, of whom 26 were interviewed. Participants represented healthcare professionals with various characteristics (age range 18–56+ years).

The Burnett et al.17 study did not include a specific statement regarding methodology; however, it appeared to be a qualitative descriptive study that utilized in-depth face-to-face semi-structured interviews and purposeful sampling to explore patients’ narratives from their experiences relating to HAIs and hand hygiene. Interviews were guided by a brief structured list developed to prompt the researcher to discuss key issues. Interviews were audio recorded and transcribed, field notes were also taken and data were thematically analyzed. There was a total of 20 adult patients interviewed either in hospital (n = 4) or in their home (n = 16) utilizing audio recordings, field notes and transcription.

The Wyer et al.18 study, as reported in 2015, conducted ethnographic fieldwork using video reflexive ethnography, with 300 hours of ethnographical observations, 11 hours of video footage and eight occasions of video reflexive sessions.18 Participation of the 14 English-speaking adults was voluntary, and the study was conducted in the adult in-patient acute hospital setting. A methodological strength of this paper was the use of co-interpretation of data between the researchers and participants, which was then transcribed and entered into the database.

As can be seen from Table 2, there were a total of five studies considered for inclusion; however, through critical appraisal, two studies were excluded, and the following synthesis was therefore based upon three studies.16-18

The quality assessment of these three studies is reported in Table 3.

Table 3
Table 3:
Final assessment table (JBI-QARI critical appraisal instrument)

All of the included studies were critically appraised utilizing the JBI-QARI Critical Appraisal Checklist for Interpretive and Critical Research.14 All included papers scored between 6 and 9 out of 10. Studies that did not specifically describe a philosophic perspective were rated as unclear for question 1 rather than “no” if they did not describe a philosophic perspective, but reported or inferred a methodological perspective.

The scoring patterns for the three included studies are presented in Table 3, which indicates that the included studies had the same scoring patterns for answers to the 10 appraisal questions with the exception of the following questions:

Q 1: Is there congruity between the stated philosophical perspective and the research methodology?

Q 6: Is there a statement locating the researcher culturally or theoretically?

Q 7: Is the influence of the researcher on the research, and vice versa addressed?

Q 9: Is the research ethical according to current criteria or for recent studies, and is there evidence of ethical approval by an appropriate body?

Findings of the review

The current systematic review is based upon data extracted from three papers, which resulted in two synthesized findings supported by four and three categories, respectively; the total number of categories was seven.16-18 Synthesized finding 1 was supported by four categories from 17 findings. Synthesized finding 2 was supported by three categories from 12 findings. All findings were informed from illustrations from the included studies (refer to Appendix IV).

Each finding had an assigned level of credibility based upon the Joanna Briggs Institute levels of Credibility. The three levels or degrees of credibility are as follows:

  • Unequivocal (U) – evidence beyond reasonable doubt
  • Credible (C) – although an interpretation, plausible in view of data
  • Unsupported (Un) – findings not supported by the data.

None of the findings in this systematic review were graded as unsupported (Tables 4 and 5). The total number of findings from this systematic review was 29, with 10 being credible and 19 unequivocal. Specifically, synthesized finding 1 had five credible findings and 12 unequivocal findings. Synthesized finding 2 had five credible findings and seven unequivocal findings.

Table 4
Table 4:
Results of first meta-synthesis of qualitative research findings
Table 5
Table 5:
Results of second meta-synthesis of qualitative research findings

The extracted findings were consistently supported by research participant quotes that adequately informed and supported the finding. Following the assignment of a level of credibility, each of the findings was then categorized or aggregated into statements that represented the findings based on similarity of meaning.

Through this process of categorization, the findings from the included studies were grouped together into a total of seven categories based upon similarity of meaning. The categories were then subjected to meta-synthesis to produce synthesized finding(s) for the purpose of providing an evidence base for practice as well as recommendations for practice and research. The synthesized findings, their categories and findings are reported in the remainder of this section.

Meta-synthesis 1: Organizational structures, culture and behaviors

Synthesized finding 1 was the result of the identification of four categories from 17 findings. The findings were supported by illustrations taken directly from the papers that reflected the patient, consumer and/or healthcare professional's voice (refer to Appendix IV).

Synthesized finding 1: Organizational structures enable partnering between healthcare professionals and patients for hand hygiene compliance; however, the culture, beliefs and behaviors of healthcare professionals and patients do not fully support this partnership.

Summary

There is evidence that within organizations there are enablers for partnering for hand hygiene, such as equipment, sinks, information sheets and educational videos; however, the behavior and culture do not appear to fully support partnering for hand hygiene compliance between healthcare professionals and patients.

Synthesized finding 1 indicated that there was evidence of enablers for hand hygiene at an organizational level, such as the provision of hand basins in which to perform hand hygiene as well as the availability of hand gels and rubs. In addition, promotional materials for hand hygiene practices such as information sheets and educational videos were available. However, despite these organization-based facilitators for hand hygiene practice by healthcare professionals, there was evidence that the behaviors of healthcare professionals and the prevailing culture within the acute healthcare setting did not fully support hand hygiene initiatives such as partnering with patients. Patients themselves also presented challenges to partnering with healthcare professionals for hand hygiene compliance, and despite being provided with information and education about the importance of hand hygiene, there was reluctance to partner due to perceived lack of knowledge and a fear of retribution form healthcare professionals.

There were mixed findings in relation to the importance that patients placed on the action of undertaking hand hygiene versus the wearing of gloves by healthcare professionals. The evidence from the findings intimated that while patients acknowledged the importance of hand hygiene, the wearing of gloves was seen as a normal, highly visible procedure that represented safety. There was a prevailing theme that appeared to indicate that glove use conveyed a perception of safety to patients, and for many patients, gloves had come to represent safety.18

The patient's perception that staff wearing gloves represented safety was supported by the illustrations of patients reporting and noticing if healthcare professionals were wearing gloves: “The first thing I noticed was she wasn’t wearing gloves.”18(p.1722) The presence or absence of gloves being worn by healthcare professionals appeared to raise questions and concerns for some patients, with one reported noting that gloves weren’t worn and questioning, “Is that normal procedure?”18(p.1722)

Staff appeared to understand their responsibility to minimize the risk of infection, including cross-transmission of infection between patients and to themselves. Healthcare professionals expressed a positive sense of responsibility to provide care for their patients and to prevent infection. In addition, healthcare professionals were concerned about the risks of cross-infection between patients, between staff or to their own families. A nurse from the Seibert study was quoted as stating, “First of all I feel responsible for the person I am dealing with, that's where if really impacts me …. If I touch somebody and I haven’t washed my hands properly, then I am going to be the carrier and trigger for that MRSA to go forward.”16(p.406)

Healthcare professionals’ concerns about cross-infection and the impact on their home life was also expressed, with one stating, “So I know it affects my daily life here and I don’t want to bring anything home.”16(p.410) Results on staff experiences included inhibitors to optimal hand hygiene and/or infection-control practice, including time constraints, staffing and negative impact of personal protective equipment (PPE) on patient safety and the inhibition of the healing touch. Staff were reported as stating “getting gowned, gloved, washing my hands before and washing hands after … it definitely takes a lot of time”.16(p.407) Healthcare professionals were also reported as stating “Well I’m only doing this one little task; it doesn’t matter … do I really need to put on and use all the isolation or all the preventative things I should?”16(p.406) The impact on the healing touch was expressed by a nurse who stated, “A barrier to touch, just to provide comfort or a healing touch … goes away when you have the barrier of personal protective equipment.”16(p.406)

The study by Seibert et al.16 noted that healthcare professionals were educated and knew what was the right thing to do in relation to hand hygiene. Given this evidence, it brings into question the drivers of behavior that contribute to poor hand hygiene compliance by healthcare professionals if lack of education or knowledge deficit is not a barrier. Education of patients on the importance of hand hygiene and how to engage with healthcare professionals was identified as a significant component of involving patients with hand hygiene promotion and speaking up to healthcare professionals.16

Patients and their families had differing levels of comfort and mixed attitudes as to whether to ask questions or challenge healthcare professionals about hand hygiene, as there was a belief that the healthcare professionals were the experts. The patient's experience also included tension with regard to expectations that the doctor and nurse were the experts, and therefore there was a presumption that they would know what they were doing. One patient, when discussing whether or not they would speak up, stated, “I’d try, I don’t know if I would do it every time, But I’d be wary of who and I’d tell my nurse.”18(p.1726) Another stated, “It would be hard to ask because they’d think you were undermining them.”18(p.1723) Some patients stated that they felt quite comfortable asking staff questions about their HAIs or infection control issues. A patient was reported as stating, “There was a band of doctors round every day, I would have been happy enough to have asked them.”17(p.44)

Meta-synthesis 2: Knowledge, relationships and impact on care

Synthesized finding 2 was the result of the aggregation of three categories from 12 findings (refer to Table 5). The findings were supported by illustrations taken directly from the papers that reflected the patient and or healthcare professional's voice.

Synthesized finding 2: Patients have differing levels of knowledge and balance partnering in hand hygiene against possible detrimental impacts on the caring relationship provided by healthcare professionals, out of concern for their own wellbeing, health outcomes, treatment and/or recovery.

Summary

Patients are concerned that if they speak up for hand hygiene, they may adversely affect their relationship with their healthcare professional and this in turn may translate into receiving poorer care. Patients fear alienation, avoid difficult conversations regarding hand hygiene and endeavor to help the healthcare professionals save face.

Synthesized finding 2 identified that one of the reasons patients did not feel they could challenge staff was that they believed that they did not have the required knowledge (refer to category one in synthesized finding 2 – Table 5). In addition, patients expressed concerns that if they did ask questions and/or challenge healthcare professionals, it might negatively impact on the care they were receiving. Patients feared that if they asked questions or challenged staff, they were at risk of being alienated by staff, with one stating, “You don’t want to alienate yourself.”17(p.44)

The patient's experience also included fear of retribution from staff providing care. Patients were cited as saying “If I offend them today, what are they going to do to me tomorrow?”18(p.1723) It appeared that for some patients in the studies, fear of retribution and negative reaction from staff materialized, as one patient stated, “When I did speak up, the nurse took a grudge.”17(p.44) A patient from the Wyer et al.18 study stated, “I’d try. I don’t know if I would do it every time. But I’d be wary of who, and would tell my nurse.”18(p.1726) This review found that the backup plan for a patient who noted poor compliance with hand hygiene was to tell another care professional.

Despite expressing a desire to partner and challenge or question staff, some of the patients in this review undertook more covert, discrete and at times quite innovative ways to partner with their healthcare professionals for hand hygiene compliance. The less common and perhaps more innovative partnering interventions employed by patients if they noticed poor hand hygiene or infection control practices by staff included intentionally contaminating the aseptic field or touching a care professional's gloved hand. Patients reported, “I’d probably try to grab her gloves or something – just destroy the field so she’d re-glove.”18(p.1726) It appeared that these non-verbal interventions were a strategy to avoid having to directly challenge staff and to avoid speaking up.

Patients were shown to experience a sense of disempowerment in relation to infection prevention and control. As illustrated in the categories from Table 5, the level of confidence in relation to avoiding an infection while in hospital was varied. Patients made statements including, “I mean you come in here, you do what they tell you to do and that's it.”18(p.1722) Some patients’ comments reflected a certain resignation or passive role during their healthcare episode, with a patient stating, “Me? I can’t really do much.”18(p.1722) Patient confidence was further eroded by healthcare professionals’ comments, with a patient reporting a consultant commenting on the patients’ infection by saying, “It was hardly surprising I’d had an infection seeing the length of time I’d spent in the ward.”17(p.45) Another healthcare professional had stated, “If you spend a long time in hospital, you’ll probably pick up MRSA.”17(p.45)

Discussion

The aim of this review was to investigate and synthesize the existing evidence relating to the experience of adult patients and healthcare professionals in the acute healthcare setting when partnering for hand hygiene compliance. A comprehensive search of the literature utilizing the a priori search and selection criteria resulted in a small number of included studies (n = 3). While there were quantitative, text and opinion papers that reported findings and outcomes relating to data and evidence obtained from surveys and questionnaires, limited qualitative research was identified as being relevant to the criteria for inclusion regarding the patient experience for partnering for hand hygiene compliance in the adult acute health setting.

A qualitative systematic review that draws upon the JBI approach to meta-aggregation does not include a re-analysis or re-interpretation of the primary literature. Rather, the reviewer extracts findings verbatim from reports, aggregates these into categories and finally into synthesized findings based on similarity in meaning and authenticity with the participant voice that was captured in the original studies. This meta-aggregative systematic review produced two synthesized findings from seven categories that were developed from the 29 findings extracted from the three included studies, supported by illustrations taken directly from the studies (Appendix IV).

The synthesized findings indicated that there was evidence within organizations of enablers for partnering for hand hygiene in the acute care setting. These included the provision of trained healthcare staff, appropriate equipment, sinks, patient and staff information sheets and educational videos and posters. However, the culture and associated behaviors of healthcare professionals and patients did not appear to fully support partnering between patients and healthcare professionals for hand hygiene compliance.

Education was seen to be an enabler for patients to be empowered to engage with healthcare professionals for partnering in hand hygiene. The quantitative literature also promoted education as a “win win strategy” for patient empowerment and hand hygiene.19 Patient empowerment appeared throughout the literature as an enabler of various patient safety interventions including hand hygiene; however, questions were raised regarding the role of patients in influencing the hand hygiene actions of healthcare professionals.20 Findings from this review indicated that partnering with healthcare professionals for hand hygiene is a complex interaction and one that is influenced by multiple subjective and objective factors. In theory, education and empowerment are considered to be major enablers for partnering; however, the findings showed that there appeared to be a disconnect and wide variation in patient acceptance of this strategy. Despite expressing a willingness to be empowered and partner for hand hygiene, evidence from quantitative data indicated that actual follow-through on and practicing of empowerment for hand hygiene compliance ranged from as low as 5% to up to 80%.20

The patient being educated and empowered to challenge staff and their actual act of asking a healthcare professional a question, such as have you washed your hands, is a unique patient experience. The experience is influenced by a variety of factors, such as levels of education, health literacy and psychosocial factors.4 This review identified differences in the levels of comfort patients experienced in challenging staff and asking questions about HAIs or infection prevention control issues. Patients also expressed fear and considered possible repercussions on the care provided to them in hospital before they questioned the practice of the healthcare professionals.

Fear and difficulties in speaking up for safety in health care is not an exclusive patient experience. Maxfield et al.21 reported various instances where healthcare professionals failed to hold crucial conversations relating to broken rules, safety breaches and errors. The reported reason as to why the healthcare professionals did not speak up to one another included fear of angering their colleagues and the repercussions on working relationships. Evidence implies that the prevailing reasons why both patients and healthcare professionals do not speak up for safety is a shared concern about damaging relationships and that fundamentally confronting people is difficult.21

The challenges associated with the implementation of programs that involved empowering patients to speak up is further discussed in a letter to the editor of Infection Control and Hospital Epidemiology in 2012.22 Reid et al.22 stated that “hand hygiene is one of the most effective means of tackling HAIs. However, rates of hand hygiene compliance remain less than optimal”.22(p.531) The letter went on to identify that hand hygiene and patient empowerment was supported by the WHO guidelines and that encouraging patients to speak to their healthcare professionals about hand hygiene was a potential means of improving hand hygiene compliance. However, patient engagement and empowerment programs were not well studied, and it was hypothesized that certain characteristics including healthcare professionals’ seniority and gender could influence a patient's willingness to question them.22

As highlighted in the background to this systematic review, Australian hand hygiene data from Hand Hygiene Australia, which publically reports hygiene compliance rates among care professionals, indicate differing hand hygiene rates among healthcare professions. Significantly, there is variation in the hand hygiene compliance data between the professional disciplines as well as between the moments for hand hygiene. The 2013 data reported hand hygiene rates for nurse/midwives at 82.9% and medical practitioners at 65.8%.3 More recent data from 2015 period 3, from Hand Hygiene Australia, indicate a persistent discrepancy between the professions, with the following reported compliance rates, nurse/midwives 86.8% and medical practitioners 71.8%.23

The first synthesized finding illustrated that patients had a belief that gloves provided safety from infection and reported observations about glove use by healthcare professionals. Patients expressed a belief that staff who wore gloves were sterile, when in fact staff were wearing clean gloves only. The perception regarding safety focused on equipment and resources available to staff. Patients in the studies appeared to have varying levels of knowledge and placed different emphasis regarding hand hygiene practice by staff and the wearing of gloves. Some patients placed a greater emphasis on staff wearing gloves as an infection control measure as opposed to them performing hand hygiene. Conversely, some patients did not express concern when staff undertook procedures such as inserting a cannula with an ungloved hand, as they had witnessed the staff member washing their hands.

The current review showed that health professionals understood their responsibilities to minimize the risk of HAIs to their patients. There was a prevailing positive association among staff with their attitude and responsibility to provide care to their patients. Some staff reported that there were no challenges around infection control practice, as hand hygiene was simply standard practice. However, some staff did report certain challenges with regard to performing hand hygiene and also the wearing of PPE.

There was a prevailing opinion from both patients and health professionals that education and opportunities to gain knowledge would be beneficial. Education was thought to be an enabler to promote buy-in as a way to encourage people to do the right thing and to increase patient involvement in prevention.

Another opinion among staff and patients was that hand washing required a collective approach, with staff recognizing the importance of teamwork and a group understanding of the importance of hand hygiene. Patients also expressed a desire to partner in prevention of infection and proposed the idea of being a community where “everybody does a bit and it helps”.18(p.1722) However, this review showed that there are differing levels of comfort among patients about asking healthcare professionals questions or challenging practice. The level of comfort appears in part to be influenced by the patients’ belief that healthcare professionals were the experts and would or should know what they were doing. There was a reported level of awkwardness some patients experienced about what they felt was challenging authority.

The quantitative evidence supported the review findings, with reports that intimated that patients predominantly did not feel comfortable asking, challenging or partnering with healthcare professionals in relation to them complying and performing of hand hygiene.24 Patients indicated they had a real and/or perceived fear of retribution and negative consequences for their care. Patients saw the healthcare professionals as the experts and, in regard to hand hygiene, were of the understanding that healthcare professionals knew how and when to perform hand hygiene.25

Synthesized finding 2 was supported by three categories that were developed from 12 findings supported by illustrations taken directly from the studies. The second of the two synthesized findings of this review indicated that patients were concerned that if they spoke up about hand hygiene, it might adversely affect their relationship with their healthcare professionals.

Patients balanced participating and partnering with healthcare professionals for hand hygiene compliance against a number of possible, real or imagined factors associated with their episode of care in the acute care setting. Patients were concerned that a damaged or poor relationship with their healthcare provider arising from their speaking up could result in them receiving poorer care and less optimal treatment, which could adversely affect their recovery from illness.

Patients expressed a belief and trust that the healthcare professionals would know how to do the right thing. Significantly, patients appeared to have different levels of comfort when considering partnering for hand hygiene. The differing levels of comfort were associated with the role and perceived level of authority of the healthcare professional, for example, a nurse versus a doctor. Some patients reported that they did not always speak up to doctors and reported breaches to the nurses rather than directly challenging missed hand hygiene practices.

The current review found that patients devised alternative non-confrontational and/or non-verbal strategies to partner for hand hygiene compliance. This in part appeared to be driven by a self-motivated desire to avoid what was perceived as a difficult conversation and also as a desire to enable the healthcare professional to save face. Patients reported using humor or indirect hinting about hand hygiene as well as more extreme physical interventions such as touching the nurse's gloved hand or contaminating the sterile field so as to stop the episode of care proceeding.18

Patients appeared to lack confidence in the healthcare system and their own realm of influence, resulting in feelings of passive resignation to infection while in hospital. Patients also appeared to be cognizant of and had regard for professionalism and experience of the healthcare professional, whom they considered to be experts and to hold a position of authority.

The current review identified varied levels of confidence and perception in the role patients played in infection control and hand hygiene practice by healthcare professionals. Perhaps compounding this lack of understanding about the role of the patients in partnering in infection control and for hand hygiene were issues with communication. Communication appeared to be a significant concern for some patients (Table 5), with some reporting that communication was poor during their stay and they received little or no written or verbal information.17 Some patients reporting not knowing that they had an infection until they got home but never actually found out what they had.17 There were differing levels of perceptions and beliefs about the role of the hospitalized patient, with some reporting that they had no role to play in infection control.

Conclusion

The patient is the single constant throughout a healthcare encounter, and this needs to be remembered and considered when assessing, planning, developing and evaluating interventions designed to promote partnering for hand hygiene. Patients should be placed at the center of the decision making process, and strategies and actions appraised and reviewed from the patient's perspective.

The findings of this review indicate that the patient's experience relating to partnering for hygiene compliance with care professionals present significant challenges, and the intention to speak up and partner does not always translate into action. Patients express varying levels of comfort regarding asking questions or challenging healthcare professionals. The influencing reasons on the patient decision making process, and the lack of intention being followed by action are multi-factorial and steeped in both objective and subjective drivers of behavior.

Evidence emerging from this review indicates that patients and healthcare professionals experience a variety of factors that act as facilitators and barriers to partnering for hand hygiene compliance in the acute adult healthcare setting. These include assumptions, infrastructure, expectations, sense of responsibility, confidence, emotions, education, knowledge base, culture and behaviors, all of which significantly impact on the partnership between the patient and the healthcare professional.

The review also indicates that patients balance participating in hand hygiene advocacy and partnering against the possible negative impact on the caring relationship between the patients themselves and the healthcare professional. In addition, the patient's illustrations provide first-account evidence that patients are concerned that challenging and speaking up may negatively influence their wellbeing, health outcomes, treatment and recovery from illness.

Balancing participation is perhaps made difficult, as the evidence-insinuated scales are already tipped against the patient due to both self-perceived and at times confirmed barriers. Patients appear to be concerned that if they speak up for hand hygiene compliance with their healthcare professionals, it may adversely affect their relationship. Damage to this relationship is seen by the patients as a risk, and one that could result in them receiving poorer care, which then could lead to adverse outcomes. In addition, patients fear alienation, avoid difficult conversations regarding hand hygiene and endeavor to help the healthcare professionals to save face.

Given that partnering and patient empowerment is a focus of many hand hygiene compliance initiatives, it is interesting that only a small number of qualitative studies were identified in the literature. Internationally, nationally and at a local state level, the importance of partnering and empowering patients and consumers is promoted and recommended as part of successful hand hygiene compliance campaigns. Both the WHO4 and the Australian National Safety and Quality Health Service Standards5 provide recommendations, and in some instances mandated standards, relating to patient and consumer partnering and empowerment for enhancing and improving hand hygiene compliance among healthcare professionals.

The current review indicates that there is a disparity between healthcare professional's promotion and intention of partnering for hand hygiene compliance and the actual patient acceptance, participation, partnership, experience and implementation of this initiative. This disconnect between intention and action is influenced by a number of factors including organizational structures as well as cultural belief and behavioral drivers.

Potential limitations of the systematic review

The aim of the review was to seek evidence in relation to the patient and healthcare professional experience of partnering for hand hygiene compliance. The availability of qualitative studies for inclusion in this review was lower than had been anticipated from the initial scoping search. In contrast, there were a larger number of quantitative and text and opinion papers; however, these did not specifically provide evidence of the patient's and healthcare professional's experience. This review was limited to studies that could be identified from English language literature, which represents a limit in terms of papers from other language groups not being represented in the findings of this review.

There were no issues identified in relation to the quality of the research, methodology and evidence of patient voice, with sufficient examples of interactions with participants reported in all of the included studies.

Implications for practice

The recommendations identified in this review have been derived from the available evidence as per the illustrations, findings, categories and final synthesized findings. The intention of the recommendations is to provide credible evidence to inform practice and policy with the aim to improve the patient experience in relation to partnering with healthcare professionals for hand hygiene compliance. Recommendations were assigned as Grade B, according to the JBI Grades of Recommendation.26

  • Healthcare professionals may develop and implement patient and staff education campaigns that clarify the benefits of hand hygiene and the appropriate use of gloves in the acute care setting. (Grade B)
  • Healthcare professionals and patients should be provided with information that promotes greater understanding of the relationship between the risk of HAIs and compliance with hand hygiene, as well as clinical responsibilities. (Grade B)
  • It is conditionally recommended that healthcare professionals and hospitals establish behaviors, environments and work place cultures that support, promote and encourage behaviors that enable partnering for hand hygiene. Partnering for hand hygiene should be an option for patients who wish to voice their concerns, and staff should be trained to encourage patients to exercise this option. (Grade B)
  • Hospitals should continue to support organizational structures that enable healthcare professionals to partner with patients for hand hygiene compliance. (Grade B)
  • Quality improvement initiatives should focus on identifying barriers to partnering for hand hygiene and resource-associated improvement campaigns. Campaigns should include components that seek to understand the different levels of the patient's comfort and real or perceived power imbalances in relation to speaking up to healthcare professionals for hand hygiene compliance. (Grade B)
  • Healthcare professionals and patients should seek to understand the experiences in relation to hand hygiene and develop strategies to overcome barriers to open conversations without fear of retribution or impact on care. (Grade B)
  • Patients and healthcare professionals should facilitate processes and communication strategies that address patients’ feelings of resignation to infection as a part of the healthcare experience and encounter. (Grade B)

Implications for research

Further qualitative studies should be undertaken in the area of partnering for hand hygiene in the acute care setting, both from the patient's and healthcare professional's perspectives.

  • Further studies should clearly report the philosophical framework and methodology for their chosen approach.
  • For qualitative inquiry, future research should locate the researcher culturally and theoretically and describe the impact of the researcher on the researched and vice versa.
  • Research should be undertaken regarding the patient's understanding about glove use versus hand hygiene.
  • Research should be conducted to deepen our understanding of patients’ and healthcare professionals’ varying acceptance of hand hygiene compliance rates and the drivers, behaviors, assumptions and culture underpinning this phenomenon.
  • Research should be conducted on patients’ confidence levels, and seek to understand the barriers and facilitators to patients’ confidence in the healthcare setting as well as to understand if and why patients and staff perceive partnering, questioning and challenging to be confrontational.
  • Healthcare facilities and hospitals need to expand on current hand hygiene campaigns and further the promotion of the transparency of reporting hand hygiene data by collecting qualitative, experiential data along with statistics.

Appendix I: Search strategy

Example: MEDLINE

Searched in May 2015

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Appendix II: Characteristics of included studies (JBI-QARI)

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Appendix III: Excluded studies and reasons for their exclusion

1. Lee K. Student and infection prevention and control nurses’ hand hygiene decision making in simulated clinical scenarios: a qualitative research study of hand washing, gel and glove use choices. J Infect Prev. 2013;14:3.

Reason for exclusion: This study did not fit the systematic review PICo.

The study was related to the decision making process regarding the use of personal protective equipment (PPE) and gel use over hand washing by healthcare professionals.

The study focused on nursing students and infection prevention and control nurses being recorded while working through clinical scenarios on a computer.

The focus was on the interpretation of answers to set clinical scenarios and the subsequent development of a risk assessment self directed learning tool, as opposed to the lived experience of partnering with patients for hand hygiene compliance.

2. Schwappach DLB, Gehring K. ‘Saying it without words’: a qualitative study of oncology staff's experiences with speaking up about safety concerns. BMJ Open. 2014;4.

Reason for exclusion: This study did not fit the systematic review PICo.

Healthcare professionals’ voices on speaking up to colleagues and safety breaches did not align with the phenomena of interest of the systematic review.

The study did not have a focus on the patient and healthcare professional partnering relationship for compliance with hand hygiene. It particularly reported on breaches relating to medication errors, isolation and hygiene, treatment decisions, invasive procedures, communication and ordering of laboratory tests.

Appendix IV: List of study findings

Healthcare-associated infection and the patient experience: a qualitative study using patient interviews. Burnett E, Lee K, Rushmer R, Ellis M, Noble M, Davey P. 2010.17

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Preventing transmission of MRSA: A qualitative study of health care workers’ attitudes and suggestions. Seibert, D J, Speroni K G, Oh K M, DeVoe M C, Jacobsen K H. 201416

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Involving patients in understanding hospital infection control using visual methods.

Wyer M, Jackson D, Iedema R, Gilbert G L, Jorm C, Hooker C, et al. 2015.18

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    Keywords:

    Compliance; hand hygiene; healthcare professional; healthcare worker; patient participation

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