Evidence Based Care: Hand Hygiene

Utilising Evidence Based Care

This essay endeavours to investigate hand hygiene, and feel I need to gain more knowledge in this field by utilising the available evidence effectively. I also intend to discuss nurse held traditions, customs and rituals.

The common method of handwasing is usually with unmedicated soaps, whist an anti-bacterial soap may be used for total hand decontamination. (Hugonnet & Pittet 2000). As nursing staff can wash their hands up to forty times per hour, it may be one of the most frequently practiced nursing skills (National Patient Safety Agency, 2004). According to Pittet (2000) healthcare professionals barely reach fifty per cent compliance with handwashing. Holland, Jenkins, Soloman et al (2003) point out that hands are the primary factor is spreading bacteria, especially as they come into contact with body fluids, furniture, dressings and equiptment.

During a placement on a surgical ward I witnessed poor hand hygiene and felt I needed to deepen my knowledge of effective and appropriate hand washing to be a competent, safe practitioner. Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure against transmission of hospital acquired infection between patient to patient (Gould et al (2007). As a health care professional I am aware I must work within the guidelines of the Nursing and Midwifery Council (NMC) and the government body, the Department of Health (DoH). Within this essay I intend to utilise two sources of research, critique them, and use the findings accordingly.

The Nursing and Midwifery Council Code of Conduct (2008) states that ‘care and advice to patients must be based on the best available evidence’ (NMC 2008 p4). Fitzpatrick (2007) states ‘healthcare professionals must demonstrate effective integration of evidence, including findings of research into their decision making.

‘Evidence based practice is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available clinical evidence from systematic research ‘Sackett et al (1996).

Within evidence available for utilisation is an evidence hierarchy. At the top of the hierarchy are well designed randomised controlled trials. The UK Cochrane Centre specialises in random controlled controlled trials (RCTs). The Cochrane centre operates globally to maintain and publish up to date reviews of randomised controlled tests for health care. (Sheldon and Chalmers 1994). Hamer (1999a) also states that randomised controlled trials (RCTs) are frequently called the gold standard of research evidence. The Cochrane Centre work out the validity of research by grading them. Grading starts at A-C, A being the highest score, and showing it has met all the quality requirements (Mulrow & Oxman, (1997). Hierarchies are also used in clinical guidelines, graded by both standard of evidence and recommendations. The highest standard of evidence grade, matched by the highest recommendation grade, suggests superior validity and ought to be considered to be implemented in practice (Cook et al, 1992)

Research evidence appropriateness can be based on how the data was collected. Examples of different research designs are RCTS, case-controlled studies, cohort studies, professional, or qualitive. The two research paper I am examining use a mix of methods.

Lockett (1997) claims evidence-based practice is a combination of scientific and professional practices. The ‘evidence -based’ aspect refers to scientific rationale and the ‘practice’ part refers to behaviour of the healthcare professional (Lockett 1997). The importance of evidence -based practice is highlighted by Hamer (1999b), stating the primary aim is to aid professionals in effective decision making to reduce ineffective, inappropriate possible hazardous practices. This would suggest, as with guidelines set out by the NMC that the use of evidence-based practice has much rationale. The American Nurses Association (2003) points out that in order to enable nurses to tally with the expectations of society, a strong evidence base for practice is essential. Furthermore, for nursing to be recognised a genuine profession, it is essential to have all of its practices based on evidence (Royal College of Nursing 1982).

Once a topic had been chosen to explore I conducted a search via databases. I found initially to use solely the term handwashing, which yielded a surplus of data.

I set the date parameters on the search to the last 5 years to maximise the validity of the research, which not only provided more suitable data, but narrowed the search to yield less results. This facilitated the search for relevant research. I added other words to the search, such as compliance and the word and/or. Also truncation was used, this maximised the search further. Especially as there are many variations of the work handwashing. Furthermore, handwashing was not the only term used to describe handwashing, hand hygiene was also used. This too, yielded successful results. The term nurse was also added, this too was truncated to nurs*, which allowed terms such as nursing, nurses, nursed to be detected, thus increasing the probability of locating the desired results. I set the parameters to detect full text and on the English language.

As I am not accustomed to using databases I sought the advice of the librarian, EBSCO, CINAHL and BNI were recommended resources. Also the Cochrane library has been praised as the gold standard in randomised controlled studies. As randomised controlled studies are at the top of the hierarchy of evidence I decided to seek a randomised controlled study. I found located the primary piece of evidence from the Cochrane library.

On this occasion I did not use main stream search engines, although I would consider using a search engine in the future to find research. Fitzpatrick (2007) claims internet searches engines can yield credible results.

My second piece of research was discovered on Ovid. Once selected, Ovid requires users to select databases within that database. I excluded paediatrics as this was not relevant to the search.

|Interventions to improve hand hygiene compliance in patient care conducted by Gould (2007) is the selected primary source.

The quality of the abstract was clear, with sub heading, and reflected the aim of the paper and its content. The objectives were to assess the long term success and improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene can lower hospital infections. This was relevant to my search as this is an area I wanted to increase my knowledge on, and utilise in practice, if the research is deemed valid and credible.

The types of studies used were randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series analyses (ITSs) meeting the requirements of the Cochrane Effective Practice and Organisation of Care Group (EPOC).The research is a systematic review. According to Mulrow (1995) systematic reviews do the ‘hard work’ of critiquing the research so time limited health care workers can access valid data. Systematic reviews are the gold standard of research (NHS Centre for reviews and Dissemination, p.1 1996):

‘Systematic reviews locate, appraise and synthesis evidence from scientific studies in order to provide informatative, empirical answers to scientific research questions.’

Muir & Gray (1997) and Sackett et al (1997) claim randomised controlled trials are thought to be the most dependable and trustworthy source of evidence.

I interpret the above as indicting the research may be of a high standard to meet the criteria of the Cochrane Effective Practice and Organisation of Care Group (EPOC). Although the research paper is not yet fully critiqued, this is a positive validity indicator.

The participants were target groups, of doctors and nurse. Theatre staffs were excluded due to different hand hygiene techniques being used. To exclude theatre staff was relevant as hand hygiene is part of the ‘scrubbing in’ ritual, and if included may have caused inaccurate results.

Data collection and analysis was conducted by two reviews, and they accessed the data quality. All of the data they had gathered was via databases searches, and two studies out of over seventy five met the criteria review.

The author concluded no implications for practice, as the review had not been able to provide enough evidence. The implications for research were more studies are urgently needed to evaluate improvements to hand hygiene. The biasness of the paper is not easy to find out as I could not discover the professions of the researchers. It could be suggested that if they were nurses, this could create a potential for bias.

When searching for this primary piece of research I did not need to be concerned about UK and American spellings are the words used did not have UK & American versions. However in future I would chose to look for both to show abundant data. The keywords used for finding this particular piece were, hand*, hygiene, wash*, comlianc*, concordanc* and nurs*.

Quantitive research sample sizes normally exceed one hundred participants. Interviews or questionnaire have set questions. Data is usually recording statistically (Siviter 2005). The data within this research was presented in tabular form. The CASP (2006) quantitive tool was utilised in the critiquing of this research. Had the research paper been qualitive, I would have used the CASP quantitive tool. This is a valuable and effective tool in analysing the research for strengths and weaknesses (Hek & Moule 2006). Although on this occasion I used CASP to critique the paper I would in future consider using other critiquing frameworks, such as Bray and Rees (1995) and Benton and Cormack (2000) or Popay et al (1998).

As to if the research was ethical or not is indistinguishable as no consent issues arose as all evidence was found via databases. Although, consensual issues are not the only ethical issues to be considered. Beauchamp & Childress (1994) claim healthcare ethics is when moral issues and questions are raised within the healthcare realm. Respect to an individual values and beliefs are a part of being ethical. However in terms of the primary research paper there are no visible signs of a breach of ethics.

The results show that both the randomised controlled trials were poorly controlled. One trail shows an increase in hand washing compliance four months after interventions. The second trail has shown no post intervention increase in hand hygiene. The author found both samples were of low quality and was conducted over a too small time frame.

The author concludes there is not any strong evidence to make an informed choice to better hand washing. According to the author, one off teaching sessions will not expected to make any lasting changes to compliance. Further robust research is recommended by the author. Therefore, currently from this research there is inadequate data that could be utilised in evidence-based practice.

‘Hand hygiene practices: student perceptions’ is the second piece of research chosen. This is a qualitive piece of research.

The aim of the research was clear from the abstract and the title. Student nurses were interviewed to gain depth of data. Student nurses were also guaranteed anomity, which may have assisted the researcher gain rich data. Had the researcher chose a quantitive methodology, it would have been complex to achieve student’s perspectives. The NMC (2008) praises qualitive research methods as they respect patient’s individuality and feelings in the way nursing staff are presumed to, and is suitable for nursing research. According to Parahoo (2006), qualitive research may be considered to be of less value than quantitive research. Another positive aspect of qualitive research is the broad picture it provides, history, context, and the causes ( Blaxter, Hughes & Tight, 2006). Siviter (2005) defines the average qualitive research sample size as fairly small, with an average of fifteen to twenty. Data is usually gathered through semi-structured interviews and open ended questions.

The researchers who conducted the research are both nurses and have a professional interest in the paper, and it is noted that the possibility of bias could occur. This was recognised by the nurse researchers.

Evan (2003) Hierarchy of evidence concludes case studies lack validity in comparison to random controlled trials and systemic reviews.

A barrier to utilising research to support evidence-based practice may be lack of knowledge and skill. Hundley et al (2000) noted that although attempts are being made to incorporate research education into current nurse curriculum, poor analysis skills are still a barrier to reading research. Hundley et al (2000) also states time is a primary barrier to utilising evidence-based practice. Retsas (2000) offers advice in conquering the time barrier, advising organisations need to increase time to study in order for evidence-based practice to be achieved. Issues with autonomy, or lack of, have been suggested as potential barriers in the implementation of nursing research. Doctors were named as a potentially obstructive (Lacey 1994). Shaw et al (2005) suggest that to know and understand possible barrier and enablers to utilising evidence is critical in the identification of evidence-practice gaps. Grol and Wensing (2004) discuss the many different enablers and barriers that might be found when change is attempted to be implemented. These range from awareness, knowledge, motivation to change and behavioural routines (Grol and Wensing 2004).

Traditional rituals within nursing are a barrier to implementing evidence -based practice. Walsh and Ford (1990) define rituals as:

‘Ritual action implies carrying out a task without thinking it through in a problem-solving way. The nurse does something because this is the way it has always been done. The nurse does not have to think about the problem and work out an individual solution, the action is a ritual’.

Billy and Wright (1997) defend rituals, claiming some are healing, and have some positive outcomes. Parahoo (2006b) argues that rituals are when practice rationale is forgotten. Thompson (1998) discusses the research-practice gap, claiming there is a gap between knowledge and practice. This would indicate there is a gap between producers and users of research (Caplan 1982).Larsen et al (2002) argues that the research-practice gap does not exist in nursing as it is not an evidence-based profession. One way of passing on the message of evidence-based practice is through clinical guidelines. Woolf et al (1999) clinical guidelines improve quality of decisions made by healthcare professionals, although a downfall may be recommendations are wrongly interpreted.

A First Class Service (Department of Health, 1998) summarizes the government ideas for improving evidence base, and how to implement the findings. This indicates the government’s recognition of the benefits to quality of care, and its links to evidence-based practice. Since then the government has included evidence-based practice in its strategies, such as NHS Research and Development in 1992 and Making a Difference in 1999. Evidence-based healthcare was at the core of these strategies (Department of Health, 1992). In the North Bristol Trust the ‘Clean your Hands’ campaign is in use. This was implemented by The National Patient Safety Agency; Alcohol gels were put all around the trust, in an attempt to make hand hygiene facilities more accessible. Nursing staff also wore ‘it’s ok to ask badges’; encouraging patients to remind busy staff to wash their hands (Infection Control Policy and Manual North Bristol Trust, 2006).

In conclusion I have learnt there is a colossal sum of research to be potentially be utilised in practice. From accessing valid data, to having the time to critique research once in practice, to trying to implement change when in practice, I have realised there are many obstacles to achieving evidence-based practice.

Research should always be analysed to establish whether or not the data it produces is valid and if it ought to be implemented in practice or not. From the two research papers I have analysed I found that neither were valid enough to consider implementing in practice. I have also learnt that change within health care is not as easy to implement as I have previously thought, many parts of the interprofessional team must be involved. Managers are key to helping change take place. I do still believe that effective handwashing is definitely one of the most effective measures in the role of infection control. A valid, robust research paper on this essential nursing skill would aid effective hand hygiene, as currently many research paper out there do not make the grade for them to be implemented in practice.

From this I have learned a valuable lesson that just because research is there, does not necessarily make it credible and valuable.

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