Nurses' Hands as Vectors of Hospital-Acquired Infection

8/10/2019 Nurses' Hands as Vectors of Hospital-Acquired Infection

1/11

Jmmal of

Advanced

Nursmg 1991,16,1216-1225

Nurses hands as vectors of

hospital-acquired infection: a review

Dmah Gould ScMPhil

RGN D ipN CertEd

Lecturertn Nurstng, Depa rtment ofNursirtgStudies, Kmg'sCollege London, Untversttyof

London,Cornwall HouseAnnex, WaterlooRoad London SEl 8TX,England

Accepted for pubbcahon J Apnl 1991

GOULD D (1991)

JournalofAdvanced Nursing

1 6 , 1 2 1 6 - 1 2 2 5

Nurses hands as vectors of hospital-acquired infection: a review

Hospital-acquired lnfechons (HAl) are no ton ou s for the manner m which they

comphcate the course of the onginal illness, increase costs of hospital stay and

delay recovery This review will bnefly o utlme the problems presented by HA l

m developed countnes and present evidence thatStaphyhcoccus aureusand g

negative bacilh, the mam causative agents, reach susceptible patients via the

contact rather than airbom e route, predom man tly on the hands of hospital staff

Go od hand hygien e could help reduce the economic burden and patient distres

caused by MAI, but th ere is evidenc e that it is infrequently an d po orly performe

by nurses, the he alth care stafiF mo st frequently in contm uou s co ntact with

patien ts Possible reasons are explo red in an attem pt to ldenhfy strateg ies to

improve hand h ygiene

INTRODUCTION

Hospital-acquired mfechons (HAl), defined as mfedions

which are neither present or mcubatmg before hospital

admission (Scheckler 1978), are notonous for their

economic burden on the health service and dishess

brought to pah ents In consequence, the epidemiology of

HAl has attracted considerable research attention, though

prease current costs are difKicult to establish and compli-

cated to calculate if all relevant fad ors are considered, ye t

rapidly become outdated (Dixon 1978, Rubenstein

et al

1982)

Scale of the problem

InBntam and the USA, HAlcxxurswith grea test frequency

among surgical pahents The site mostfi-equentlyaffeded

IS the unnary hact, particularly among cathetenzed

pahents, foUowed by wounds and the lower respiratory

h a d (see Meers

etal 1981,

Scheckler 1978) A rehospec-

hve study of 16 hterature reports between 1933 and 1973

revealed that hospital stay was prolonged between 1 3 to

26 3days as a result of HAl (Brachmanetal. 1980) HAl

contnbutes diredly to morbidity and to mortahty (Cro

et al

1980), especiaUy among the most debihtated pah

(Bntt

et al 1978),

who are most likely to be lmm u

compromized (Zunmerh 1985) HAl most conunon

results from bactena which are present on the skm

N O R M A L S K IN F L O R A : A P P L Y IN G

KNOWLEDGE TO THE DEVELOPMENT O

HOSPITAL-ACQUIRED INFECTIONS

Reybrouck (1983) affirms that knowledge of normal sk

floraISof value in the prevention of HAl because it

vides the basis for our understandmg of the sigmfican

and incidence of chfferent types of bactena camed on sk

espeaally hands, and suggests how this informahon c

be applied to develop effedive hand hygiene pohae

This rational approach is not without problans, as t

demarcahon between what consh tutes normal and abno

malIS often hazy (Schaechter 1989) Extensive studies

Noble SommerviUe (1974) determined the compositi

of normal skinflorao becoagulase negahve Staphyloc

and Comey bactenum Greater chscrepancy reigns ov

numbers and locationAsensihve biopsy method descri


2/11

Hospital-acqmred infection

by Selwyn Elhs (1972) suggests considerable va nation m

bactenal counts on different parts of the skm, with a much

higher density m moist than dry areas

Healthy mtad skm resists bactenal invasion, both

because it exhibits a degree of self-disinfection towards

contaminants and because under normal areumstanees its

deheately balaneed eeosystem of eommensal orgamsms

help to keep foreign speaes at bay However, eontanu-

nation ean sometimes result m longer-term eolomzah on b y

exhaneous baetena, espeeiaUy when the skm is unusually

moist or damaged (Ojajarvi 1979), a factor of eonsiderable

lmportanee w hen eonsid enng preven tion of eross infeehon

Transfer of baetena from one part of the body to ano ther

site,normally free of orgamsm s, may result m lnfeehon the

dam p pennea l skm of patients with spmal eord mjunes may,

for exam ple, become eolomzed w ith coliforms (Sanderson

& Weissler 1990) Migrahon mto the bladder via a unnary

catheter results in badenuna (Sanderson & Rawal 1987)

Als o relevant is the tenden cy of hospital patients to aequire

a skm flora chfferent to that of the general population

(Montgommene Morrow 1978) whieh may eontanunate

their immediate environment providmg opportumhes for

eross uifeehon Its eons htuen t baetena may be more anti-

biotie resistant than the skm flora of healthy adult members

of the general population (Larson

et al

1986)

Considerable attenhon has been paid to the normal

flora of the hands Nearly 50 years ago, Pnee (1938)

dishnguished between 'resident' and 'hansient' baetena

through quantitative laboratory handwashmg studies

Those organisms whieh eould eventually be removed by

repeated and thorough handwashes were categonzed as

hansient, thought at the time to represent contammants

which under normal arcumstances would probably che

withm 2 4 hours of moculation The remaimng resident

badena, regarded as the true skm flora, persisted deep

m the duds of sweat glands and subungal spaces The

existence of h ansie nt an d resident hand flora on the basis of

whether o r not they can be removed by s tn d hand hygiene

has smce been venfied by Hann (1973) and Gross et al

(1979), but it has become apparent that contaminants,

espeaaUy gram ne gahve speaes , may be camed for weeks

or mo nths (Cooke rf a/ 1981,Larson 1981) Ha ndc am age

am ong appro xunate ly 20 -3 0 of hospital staff has been

reported (Bruun & Solberg 1973, Adams & Mam e 1982),

but isolahon rates of up to 80 have been men honed m

relahon to neonatal and bums umts (Kmttle

et al

1975)

W ean ng nn gs mcreased camag e rate of underlymg bactena

dunng field stucbes (Hoftnan

et al

1985), but labora tory

expen men ts have yet to don onstra te any mcreased nsk of

cross utfedion firom bactena beneath nngs Qacobsonet al

1985)

Reybrouck (1983) emphasizes th at isolation of the sam e

bactenal strains from patients and the hands of hospital

staff reported m numerous studies does not conshtute

absolute proof of eross infedion, but it is highly sugges-

tive,

espeeiaUy today with sensitive m etho ds of sero typ m g

baetena, and evidenee of sueeessful conhol of outbreaks

once a stnct handwashmg regune has been implemented

More defimte evidence of cause and effed may never

become available when mvestigatmg cross mfechon,

especiaUy by the contad route (Stamm

et

al 1981)

Today, the agents responsible for most HAl are

Staphylococcus aureus and gram negahve rods, with other

patho gens sometimes responsible for outbreaks InaUcases

there is suffiaent evidence to demonstrate that spread is

pnmanly via the contact route, with hands, the part of the

body m most continuous con tad w ith pahent and environ-

ment, probably playmg a major role The role of airbome

spread and the manimate environment as a source of HAl

wiU now be explored, eondudmg that these are of mueh

less significance

Staphylococcal infect ions

During the 1950s, Staphylococa were recognized as

responsible for mcreasmg rates of HAl (Goodall 1952,

McDermott 1956) and their abihty to develop anhbiohc

resistance was an emergmg problem (Colebrook 1955)

Early wo rk focused o n air dissem mation via skm scales as a

possible route of spread, particularly from some members

of staff identifiable as 'heavy chspersers' Expenments with

medical students dem onsha ted that approxunately 14 of

the male population acted as persistent permeal earners of

Staph aureus Dispersal of free badena mto the cur eould

oeeur dunng exerase m a speaal ehamber (Ridley 1959),

but under nonnal areumstanees these would probably

attaeh themselves to dothes Nasal eamage was reported

as more widespread, but field and laboratory stuches

mchcated that dissemination usuaUy occurred not chrectly

through the air m droplets, but by an mdired route m

which nasal secretions were first found t o contam mate skm,

dot hm g and probably hands (Hare Thomas 1956) It was

suggested that limited hansfer might occur via fnciion or

air cunrents, but later mve stigations m volvm g th e use of a

sht sampler to de te d airbom e transmission dun ng a major

staphyloccKcal outbrea k revea led t hat, if this occurs at aU, it

operates over only very short distances (Peaeoek et al

1980)

These observahons eonfirm the results of mgemous

field studies which today would probably be prohibitedcm

ethical grcHinds (Mortimer

et al

1966) These we re con-

ducted m a neonatal umt to hace spread of Sta|>hyloccx:a


3/11

D

Gould

and Streptococa from babies already colonized between

nurses and other infants There was very bt tk spread bo m

nurses to infants who were m proximity but not touchmg

When contamination viathe airbome routewas prevented,

a 43 transmission rate occurred from coloruzed to pre-

viously uncolonized babies, providing the nurse did not

wash hands between contacts Anhseptic handwashmg

reduced transmission rate t o 14

Airbome spread of Staphylococa remamsamajor prob -

lemmtheatre, espeaallywhereorthopaedic prostheses are

implanted Oalovaara & Puranen 1989) and also m bums

uruts where pahents have lost large areas of skm, the

body's chief defense against mfechon (Ayltffe

&

Lowbury

1982) In the ward, hazards of airbome spread, mduding

over short distances from skm scales on do the s, appiear to

have been over-eshmated (Mackintosh 1982) Babbet al

(1983) demonstrated that even when dothes are heavily

contaminated by Staphylococa released m large numbers

from a heavily discharging wound, this does not appear to

represent a sigruficant threat to other pattents on the same

ward

Unfortunately, the mtroduchon of new synthehc

penidlbns which brought dramahc improvements m the

treatment of Staphylococcal infections throughout the

1960s allowed complacency to develop (Cafferkey et al

1985), while promotmg multiply resistant Staphylococcal

strams Consequently, the 1970s and 1980s have been

punctuated by repeated epidemics of methialbn resistant

Staphyhcoccns auretts(MRSA) throughout the world Pob-

aes for controi vary accordmg to available faabhes and

circumstance (SpKer

1984),

but exhaushve m veshgahon of

outbreaks mdicates that hands ofiFer the duef means of

spread, with cnhcally

ill

pahen ts who become colonized or

infeded operatmg as reservou-s (Thompson et al 1982)

Nurses can become earners, conhnbuhng to nsks of cross

mfechon (Shanson 1985),afactor which maycauseanxiety

m their professional and personal bves (Tuffriell 1988)

Gramnega tive bacteria

Unbke Staphylococa, gram negahve bacteria do not

generally resist dessicahrai and controi can be effected to a

large extent b y providmgan environment thatisdea n and

dry (Maurer 1985) They tend t o colonize pahents wh o are

immunocom{n-omized and, once agam, mfection is more

bkely to follow colonizahon (Moody ela/ 1972) Initial

studies by Lowbury (1969) suggested that most gram

negahve b ad ena dry out and die rapidly when inoculated

onto human skin,

a

ccmclusirat since substanhated

by

Cooke

et al

(1981)w ho established Hiat^^ectesand shams

previously responsd>ie for

hospAt^

outbreaks were able to

survive significantly longer than 'non-outbreak' bacte

when arhfiaally moculated onto the hands of laborato

volunteers

Persuasive evidence for the hands

as

vectors of hospi

acquired gram negahve sepsis is provided by Casewell

Philbps (1977) who dem onstrated that 16 of staff m

mtenstve care unit had Klebsiella hand contammation

the same serotypes as those colomzmg pahents Labor

tory expenments showed that ba de na remained viable

to 150 minutes following arhficial moculahon onto t

hands suffiaent time for cross mfechon to occur dunn

normal nursmg duhes Qo thm g, ward

air

and dust samp

were seldom contammated, supporhng work review

earlier by Noble et al (1976) which conduded t

although som e individuals disperse gram neg ahve bacten

heavily, there is no evidence to support airbome sprea

Contmued woric over a 4-year penod demonstrated th

24 of 2315 cnhcally ill pahents became colonized wi

Klebsiella, almost always with the same capsular strai

(Casewell & Philbps 1978) Possession of a mucus cove

mg, not carnage of an anhbiohc-resistant plasmid, w

apparently the influential fador m bactenal survival o

finge r tips (Casewell & Desai 1983) Outbreaks of gra

negative mfechon have been traced to nurse earners an

arrested when culpnts were removed from patient conta

(Burke effl/ 1971)

Hand carriage of pathogenic organisms

From time to time, nurses' hands must inevitably becom

contammated with pathogenic organisms, espeaally

there is evidence that bedpan washers and disinfedio

procedures do not adequately destroyallentenc pathog

(Cune

et

al 1978, Block

ei

al 1990) Survival on hand

possible for som e hours (Samandir al 1983) and the ha

of pahents mayalsobecome contammated, mcreasmg n

of cross mfechon (Lawrence 1983, Pntchard & Hathaw

1988)

A study by Black

et al

(1981) is one of the

expenmental studies designed to show a causal li

between handwashm g and nsk of mfechon Followmg t

mtroduchon of a stnct handwashmg programm e in a d

care centre, the ino dotc e of dianhoe a among children

the study centre was significantly and consistently low

than m control centres over a 35-week pen od Lars

(1988), remaricing on the pauaty of prospechve dmic

tnals to test a causal bnk between hand hygiene and HA

attributes their absence to pioneers of the nud-mnetei

century (Seminelweis, ListeriuidN ightingale) who d^^e

sudi dramahc reduduHts m m oibidity and mortality fro

mfechcm by implementmg hygiene into health care th


4/11

Hospttal-acqmredmfechon

anhsepsis has too long been recognized as important and

benefiaal for research withholding it to be considered

viable on ethical grou nds M ost evidence comes mdirectly

from shidies already reviewed here However, if evidence

for a direct link bebv een h and h ygiene and HA I is lacking,

it IS prov ided b y w ork with respiratory pa thog ens w hich

appear t o depen d to a large extent on spread by the con tact

route (Gwaltney

et al

1978) Prev enho n is achieved whe n

hand hygiene compliance is good (Ledair

etal

1987)

H A N D S A N D I N A N I M A T E E N V I R O N M E N T

The surroun ding environ men t has little bearing on rates of

HAI (McGowan

1981,

Bauer rfa/ 1990) This is confirmed

by Maki et al (1982) m a 'natural' expenment, possible

when a hospitai moved from old to new, more spaaous

premises where facilities (including improved ventilahon

mtended to reduce airbome spread) had been upgraded

Extensive microbiological surveillance before and after the

move revealed that despite greater environmental con-

tammahon m the older building, rate of HAI remamed

unchanged

A few authors have apparently lncnminated the

environment in HAI, but m all cases a link between

environment and susceptible patient must logically exist

Bentham (1979), descnbmg an outbreak of Klebsiella,

suggested that the floor around a leakmg bedpan macera-

tor had acted as a reservoir, but acknowledges that the

route from floor to pahent was probably via nurses' hands,

unwashed after removmg overshoes Similarly, Carter

(1990) demonstrated high counts of aerobic baalli on the

floor of an mtensive care unit and on nurses' hands

Transfer could never be venfied absolutely, but is

suggested to have occurred in the same way

Links between faulty hand hygiene, equipment and

H A I

Invasive devices bypassing the body's nahiral bamers to

micro-organisms vastly mcrease nsks of HAI (Tafuro &

Rishicaa 1984) Mulhall (1990) pomts out that although

doctors are usually responsible for sitmg mtravenous

cannulae, catheters and endotracheal tubes, nurses look

after them , providing care whidi, thou gh rouhn e, is com-

plicat ed Rate s of mfechon related to parhcu lar typ>es of

equipment show considerable vanahon accordmg to the

6nchngs of an extensive multicentre madence study

(Nystrom ei al 1983), although there is little doubt that

high dependency pahents undergomg more procedures

are at grea test nsk (Daschner 1985) There is also some

evidence that nsk of sepsis is mcreased when new tech-

niques are mtroduced with which staff have limited

expenence

A prospective survey by Dumas et al (I97I) d rew

attenhon to high levels of contamination assoaated with

intravenous volume control sets, lmked to poor main-

tenance (leakage, dirty injection ports) and breaches m

asepsis, espeaally handw ashmg Later prospe chve studies

recorded lower infechon rates explamed through new, less

easily contammated designs of equipment and the simul-

taneous development of stnct protocols for asepsis

(Buxtoneffl/ 1979, Shmozafa rf / I98 3, Le ro yr fa / 1989)

Where asephc technique broke down, mfection was more

likely to supervene This evidence lends we ight to H AI

bemg dependent mainly on the contact route for spread,

with hands, which manipulate equipment, playmg a vital

role

Ha n d wa s h m g p e r f o r m a n c e

Over the years, the results of microbiology and field

studies have mdicated repeatedly that scrupulous hand

hygiene remams the smgle most important factor favour-

mg reduction of HAI (Lowbury et al 1970, Larson 1981,

Larson 1989), a suggestion which should be welcomed, as

hand hygiene is relahvely uncomplicated and mexpensive

Its aim IS to re m ove all non-resident m icro-orgarusms to

below the level necessary to conshtute an lnfechve dose

before transfer can occur to a susceptible patie nt

Although a quick, perfunctory handwash with soap and

water followed by bnsk drying has been rejwrted m one

study to remove transient bactena (Spruntet al 1973), field

and laboratory studies have reached agreement on the

sup en ont y of skm disinfectants (eg chlorhexidine and

povidone-iodine), providing the handwash is long enou gh

for them to exert efifect Som e of these age nts ex ert a

culmm ahve effect if used repeatedly, w hich soap and w ater

does not, but it is important to recognize that any agent

suffiaently gentle for applicahon to human stan will not

destroy or remove all existmg b actena

The evaluation of handwashmg is a ccHnplicated task

compnsmg not only choice of appropnate agent, but also

frequency, durahon, appropnateness (whether hands are

washed whai they should be) and perfomiance of tech-

nique (Larson & Lusk 1985) Research has consistently

show n that all aspects ma y be faulty

Albert & Comke (1981) surveym g frequency of h and-

washmg m an ITU over 1014-hou r penod s, observed that

staff washed their hands less than half the hme foUowmg

pahent contact Their cntenon iac 'contact' was strict, as

it mvolved minimal touchm g (e g pulse takmg), but is


5/11

D Gould

probably justified as CaseweU & PhiUips (1977) demon-

shated that sudi adivities can result m hansfer of 10^

CFU (colony forming units) to nurses' hands This may

be suffiaent to conshtute an lnfechve dose or result m

colonization if transferred to a very debihtated pahen t the

study was undertaken m ITU

Albert & Condie (1981) chd not attempt to document

appropnatoiess This issue has been addressed by Taylor

(1978),who estabhshed dunng 129 observations of hand-

washmg episcxles that nurses did not chstmguish between

dean and chrty situahons, a findmg later corroborated by

BroughaU et al (1984) Taylor attnbuted this to nurses'

apparent behrf that, unless visibly soiled, hands caimot

spread mfechon, although herresearchwasnot designed to

test this Handwashmg durahon is often bnef (Quraishi

et

al 1984), averagmg 88 seconds accordmg to Graham

(1990),compared to 10 seconds recommended by CDC

A possible cn ha sm of many stuches is that presence of

an observer may have mfluenced normal behaviour, even

though staff were not told the real purpose unhl after data

coUechon was com plete m most cases However, Leonard

(1986) and Larson et al (1986a) have both commented

on the encnmous vanahon m handwashmg frequency

between different nurses, suggestmg that for a task as

routme as handwashmg thereishttle evidence of Haw thorn

Effed This problemwasovercome altogether byBroughaU

et al (1984), who recorded handwashmg frequency by a

momtonng system attached to soap dispensers found m

tnals to operate w ith

93

accuracy Nurses washed hands

on an average of 5-1 0 times per shift, but claimed to do so

more often when asked to rate frequency by the researdi

team, a

findmg

substanhated by Larsonet al (1986b)

In most stuches, authors have attempted to rate only a

few of the fadors suggested by Larson & Lusk (1985),

perhapsbecause suchdo se and detailed observahonistime

consummg and difficult to orgaruze, especaaUy when the

researcfi design d ona nds that staff should be kept unaware

ofthe true purpose of the study Performance of techruque

has been examined least of aU, notably m one of the

smaUest scale stuches (Taylor 1978) Quahty of hand-

washmg tended to be pcwr, with some surfaces omitted

repeatedly

In recent years, health care professionals have become

ccHTcerrrednot cmly with preventing HAl but also p rote d-

mgthemselves againstblcx>dbom e pathogens(HTV,HBV)

by wea nng gloves when handhng blood and bcxly fluids

This has led to confiision about the need to wash hands

after gloves have been ronov ed,assomeaudK>rs claimthis

may not always be necessary Oackson & Lynch 1984) Tliis

VKW IS erroneous g b \ ^ can

become

pundured

m

use

(KoriKiwiczet al 1989), allow passa^ of virus paitides

even when mtad (Komeiwicz 1989), split under pressu

(Dalgleish Malkovsky1988) and promote mulhphca

of skm bactena by creahng warm, moist condihon

(McGinley et al 1988) They must be changed betw

every pahent as they carmot be washedfi^eeof pathogen

(Doebbelmgrffl/ 1988)

EXPLORING REASONS FOR POOR HAND

HYGIENE

The need to reduce HAl has been recognized durmg th

development of quality assurance programm es m view

the dea r relevance to pa hent safety and tangible econom

retum coupled with the relahvely measurable nature o

mfechon rates (Shaw 1986) However, CadwaUader(198

chsappomted after the implementahon of a new mfecho

conhol policy, conduded that the experhse of micr

biologists and infechon conhol nurses wdl be of limite

benefit m the absense of commitment fi-om nurses wh

must implement their suggeshons Lack of motivatio

and accountabihty for HAl on an mdividual basis ma

be contnbutory fadors Nursing Times News 199

queshonnaire study by Larson & KiUien (1982) sought

identify fadors which mfluenced staff to wash or not was

hands Inchviduals were aware of the need to reduce HA

but were deterred through the possibility of developm

sore,

dry skm The authors judged that future complia

might be secured by closer examination of deterrent fa

tors A study in the Far East ldenhfied tachcs employed b

mfechon conhol nurses to secure comphance and aske

chnical nurses to idenhfy which approaches they foun

most helpful (Seto

et

al 1990) Speaalist and ward nur

found trust based on professional resped mutuaUy mo

benefiaal than coe raon or threats from senior staff In th

UK, mfedion co nhol nurses do not occupyhnemanage

posihons m the nursmg hierarchy and it is chfficult

imagme co erao n havmg much impact m hospitals m o

scKaety

Lack of resources m ay be an issue related t o motivatio

Observmg that nurses tended to wash hands more often

a sink posihoned near the nurses' stahon, BroughaUet

(1984) proposed that more sinks placed nearer to t

pahent care areas might mcrease comphance A study b

Kaplan & McGuckhn (1986) found supporting evidenc

but Prestonet al (1981), documenhng handwashmg

infechon rates before and after the upgrachng of an ITU

chd not

Evo t when facihties are good staff may no t wash han

because they have developed sore, cbyskm, itself unde

able as this uKreases bienal

aAotazakion

(Ojaj

1981) Nurses are weU aware of th e nsks (see Larson


6/11

Hospttal-acquiral

mfechan

Killien 1982) A queshonnaire study by Newsom et al

(1988) estabbshed that choice

of

hand scrub preparahon

depended mainlyon skmtolerance This problemis not

insurm ountab le as manufacturers are now paym g mcreased

at tenhon

to

product acceptabibty Recent tnals have

demonstrated that cleansing with disposable alcoholic

wipes mcorporatmg emollients Qoneset al 1986, Butzet al

1990), antimicrobial

gel

(Newman

Seitz

1990) or an

emulsion

to

replace soap

and

water (Kolan

e t

al 1989)

can

reduce crackmg, drymg and erythema while effectively

removmg transient bactena

Related

to

availabibty

and

acceptability

of

resources

is

the issueof bemgtoobusyto usethem Throughoutthe

bterature, there

are

numerous suggeshons that

at

very

busy times hand hygiene

is

more likely

to

break down

(Lowburyet al 1970 N o o n e etal 1983), although Taylor

(1978),

in a

small-scale obse rvah on study, could

not

relate

levelsofward achvitytohandwashm g Haley & Bregman

(1982), employmg

a

mulhvanate statishcal model, cone-

lated under-staffing and overcrow dm gma neonatal nursery

to cross infection culm matmg m a staphylococcal outbreak

Incontrast to subjectsmthe studybyBroughalletal (1984),

these nurses

and

dodors recognized

and

were concemed

about defects

m

hand hygiene wh en busy

Local policy

Local pobcy may influence handwashm g and glove wean ng

specifically mrelahonto catheter care (Crowet al 1988),

though

m

this study medical speciality, diagnosis

and

reasonforcathetenzahondid not Similarly, Ho-Yenetal

(1984), employing

a

queshonnaire

to

evaluate nurses'

knowledge

of

hepaht isB,could

fmd no

difference between

nurses employed m different dmical settmgs, a result

surpnsmg

as the

nsks

of

seroconversion parallel degree

of

exposure

to

blood (Pantebckef/ 1981), a fact which might

have been reflectedm staff educational opportimities

Inevitably, poor hand hygiene

has

been attnbuted

to

lackofknowledge ,aview endorsedby Sedgwick (1984),

who pomts

out

that apart from teaching

in

relation

to

aseptic technique, nurses receive bttle guidance Possibly

thisISbecause handwashmgisregardedas a'social' rather

than

a

'technical'

or

'professional' achvity

The

impact

of

theoretical lnstruchon

on

dimcal performance

of

asepsis

appearsto be an under-researched area (Feldman1969)

Although providmg more acceptable altemahves

to

soap

and

water results

m

sbghtly improved compliance

when evaluated over short penodsoftime (Graham 1990),

there

is

limited mdicahon that 'educahonal' campaigns

ha ve efifechve long- term benefit Williams Buckles'

(1988) longitudinal quasi-expenmental study measured

knowledge and a thtudes

to

liAI before an d after staff w ere

exposedto asenesofpamphlets, postersandvideosm a

test hospitai compared

to a

control where

no

intervenhon

had occurred Handwashmg frequency detected

by

elec-

tronic monitors attached

to

soap dispensers showed

an

mcreased frequency

of

handwashmg m atched

by

increased

knowledge,but 6month s later these effects w erenolonger

apparent

Maye ret al (1986)

and

Conly

et

al (1989) successfiilly

mcreased handwashmg practicemhigh dep enden cy uruts,

but reported

a

decbne

m

compliance with mcreasmg time

since imp lementationof theeducahonaland enforcement

campaigns Initial success was attnb ute d

m

these studies

to

providing staff with feedback on rates of handwashmg,

perhaps mcreasmg their sense

of

accountabibty

Top up'

campaigns

are

probably needed

for

reinforcement with

staff tumover Becker

et al

(1990), reporhng

on

sharps

injury

and

lack

of

compbance with sharps disposal pob cy,

attnbutes the disappomtmg effects of conhn umg educaho n

to lack

of

speaficity teachmg

is

usually

the

same

for all

staff,

regardlessofdimcal settmgorlengthof expenence

This research team concluded that before improvements

m practice and motivation can be expected efforts are

necessary

to

estabbsh know ledge

and

bebefs already held

by mdividual members

of stiff,

followed

by

educahon

more tailored

to

particular need

Role models

O n

a

more posihve note, good role models

may

mcrease

hand hygiene compbance (Larson 1983) and there is

evidence that

the

mtroduction

of

mfechon control baison

nurses

dmical nurses

who

have

had

additional trairung

m mfechon con trolm ay enhance awarenessofnsksand

influence prevenhon strategies (Chmg & Seto

1990)

C O N C L U S I O N

This review has demonstrated that mcreasmg ratesofHAJ

are

due

chiefly

to

spread

by the

contact route

and

that

disseminahon must occur to a considerable extent on

nurses ' hands Hand hygiene,

the

most imp ortant means

of preventmg

HAI, is

often poorly performed, some-

hmes through lackof knowledge and also because even

when nurses have

the

requisite knowledge

of

appbed

microbiology, mohvation

is

p o o r

Poor facilitiesandequipment, bemgtoobusyandlack

of encouragement from suitable

rok

models

may be

influential,

but

their contnbution

is

present ly un know n

More time should be spent documentmg prease ly what

nurses know

zhouk

HMand how

they perform

all

aspects


7/11

D GouM

of hand hygiene before posihve attempts are made to

provide them with informahon they presoitiy lack and

encouragement to perfonn more efiechvely

In the present du na te of educationaireformat basic and

postbasic level, the prevenhon of HAI through nursmg

prachce should be regarded as an important dudlenge

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Nurses' Hands as Vectors of Hospital-Acquired Infection