Hand Hygiene

According to Marquis and Huston (2009, p.69), “Ethics is described as a system of moral conduct and principles that guide a person’s action in regard to right and wrong and in regard to oneself and society at large.” For this quality and safety “Workarounds” ethical paper, hand hygiene policy for Mercy General Hospital will be evaluated and how the practice is implemented in the clinical setting.

In conformity with Mercy General Hospital’s policy on hand hygiene, (2006, p.2) “hand washing has been recognized as the single most important measure for preventing of healthcare-associated infections.” In order to practice ethics and patient safety, health care professionals cannot do workarounds on hand hygiene.

PART 1 (A)

Hand hygiene refers to antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis (Mercy General Hospital, 2006). Guidelines indicate clinical staff should wash their hands with plain soap or antimicrobial soap and water when: hands are visibly dirty or contaminated with transient microorganisms or with blood or other body fluids, before eating, after using the bathroom, and after caring for patients with clostridium difficile (Mercy General Hospital).

For routinely decontaminating hands that are not visibly soiled the hospital recommends using an alcohol-based rub (Mercy General Hospital, 2006). Indications: Immediately before direct contact with patients, immediately before donning gloves when inserting a central intravascular catheter, immediately before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices, after direct contact with a patient’s skin, after contact with body fluids; mucus membranes, non-intact skin, and wound dressings if hands are not visibly soiled. Hand hygiene is also needed when moving from a contaminated body site to a clean body site during patient care, after contact with inanimate objects in the immediate vicinity of the patient, and after removing gloves (Mercy General Hospital).

When washing hands with soap and water first get hands wet with warm water, then apply a dime-sized amount of soap to palm of hand after rubbing hands together and covering all surfaces of hands and fingers for 15 seconds, rinse with warm water and dry thoroughly with a paper towel (Mercy General Hospital, 2006).

The policy also reviews surgical hand antisepsis and skin care products, and other aspects of hand hygiene. For instance; clinical staff cannot wear artificial fingernails or extenders when having direct contact with patients, clinical staff must keep nail tips clean and less than ¼ inch long. Gloves must be worn by health care staff when in contact with blood or other potentially infectious materials such as mucous membranes and non-intact skin. One must remove gloves after caring for a patient and change gloves between patients and practice hand hygiene prior to donning new gloves, staff must change gloves during patient care (Mercy General Hospital, 2006).

PART 1 (B)

Finding the policy for guidelines on hand hygiene, resulted in being more difficult than initially presumed. The hospital has converted to computer charting; this includes all the policies and procedures. As a result, when asking co workers and my manager to help locate the policy presented a challenge, no one knew where to look. The old policy binders that remain on the unit did not have the information. After calling the director of the unit; I learned it was located on the internet, under the hospital home page. It required a password to access the information, therefore, making it difficult for nurses to access the policy.

Originally the policy and procedure for hand hygiene was disseminated to the staff in a meeting a few years prior. However, the clinical staff nurses are normally overwhelmed and busy, as a result, nurses generally review the policy and sign a sheet indicating they read and understood the policies to get back to their patient assignments. Skimming through a policy so one can return back to work and assume their duties should not qualify as reading and understanding a policy.

According to Boyce (2002), each year nearly two million patients in the United States get an infection in hospital and about 90,000 of the patients die as a result of the infection. One of National Patient Safety Goals, effective July 1, 2010, for Joint Commission was to have hospitals comply with either Center for Disease Control (CDC) or World Health Organization for hand hygiene guidelines. Mercy General Hospital currently uses CDC guidelines as a resource for the hospital policy.

In one of the many studies outlined on the CDC website indicates nurses can contaminate their hands with gram-negative Bacillus Staphylococcus aureus, Enterocci, or Clostridium difficile by performing clean activities (Boyce, 2002). Example of clean activities include lifting a patient , taking a patient’s pulse, blood pressure, oral temperature, and even just touching a patients hand (Boyce). Health care associated infection rates were lower after using antiseptic hand washing; using a chlorhexidine, containing detergents (Boyce). An agar fingertip impression plate was used to culture the bacteria. The number of bacteria recovered from fingertips ranges from 0 to 300 colony forming units (CFUs) (Boyce). Boyce provides overviews of studies done on different hand preparation techniques for hand hygiene. The website results presents studies on the use of plain (non-antimicrobial) soap, alcohols, chlorhexidine, chloroxylenol, hexachlorophene, iodine, iodophors, quatenary, ammonium compounds, and Triclosan (Boyce). As a result, hand washing with plain soap can result in paradoxical increase in bacterial counts on the skin (Boyce).

Washing hands is a vital procedure that should be undertaken after every patient contact. Even brief contact can cause millions of colony forming units to the hand (Biddle, 2009). Thus, hand washing is the essence to reduce patients from becoming infected.

PART 1 (C)

Recollecting on a recent registered nurse (RN) deviation from the written hand hygiene policy, this nurse was in the labor and delivery room assessing the newborn infant. The particular nurse did have gloves on at the time before the delivery. However after the infant was delivered and brought to the warmer, the nurse removed the soiled towels with mother’s body fluids and took off her gloves. Instead of placing on a new pair of gloves, the nurse started assessing the infant. After placing the infant skin to skin with the mother the nurse collected her paper work and left the room without washing her hands.

The hand hygiene policy, clearly states if hands are not visibly soiled, use an alcohol-based hand rub after contact with body fluids (Mercy General Hospital, 2006). If the hands had been visibly soiled, then one should wash hands with antimicrobial soap followed by rubbing hands together and fingers for 15 seconds (Mercy General Hospital). This particular nurse might have been promoted to deviate from the policy and procedure of hand washing because that day it was extremely busy. This nurse did not follow the correct steps of hand washing and placed other patients and employees at risk for infections.

PART 1 (D)

One of the reasons why RNs may not follow the institution’s written policy could be related to being understaffed, lack of education on guidelines, or time management skills. According to Lalley and Malloch (2010, p.4), “users initially avoid using new system as much as possible and found ways to work around the system.” Evidence based practice may be ideal for patients’ care and safety, however in reality in a health care setting it may impact one’s work load. Nurses may perceive the practice as inflexible and deviate from the prescribed work.

Deviance comes from motivation for the action and personal preference, whereas workarounds is to take specific motive to complete the task (Lalley, 2010). Although hand washing for 15 seconds or even using alcohol-based hand rub routinely sounds simple, yet some nurses that have worked over 25 years in a clinical setting state, ” we never even wore gloves back then.” The senior nurses practiced medicine without evidence based practice on hand washing, thus not finding the significance in hand hygiene in preventing infection.

PART 1 (E)

“Employee’s perceptions vary as to what they owe the organization and what they owe themselves,” (Marquis & Huston, 2009). The proper response when a co-worker deviates from standard practice of policies or procedures would be initially too discuss with the nurse in a non threatening manner, the deviation in practice. If there is any resistance or the nurse continues to deviate from practice, then following the chain of command would be ideal. Contacting the charge nurse would be the next step and writing an incident report. The following step would be to discuss the unsafe practice with the manager.

In the situation where the coworker did not wash their hands, the initial response was a gentle reminder; when the nurse laughed it off, the charge nurse was notified and incident report was written. The unit manger did discuss the incident with fellow staff nurses. Initially there was some resentment, yet the nurse now complies and understands the risk of spreading pathogens.

PART 2

Ethics is a mindful action with regard to self, other humans and environment (Marquis & Huston, 2009, p. 75). Not complying with hand hygiene can result in serious complication for patient safety. Ethical principles that apply to patient safety in regard to hand hygiene are a nurse to have autonomy, beneficence and nonmaleficence (p.74).

According to Silva and Ludwick (2006, pp.1-2), “we as nurses have obligation to meet the trust and the subsequent duties to the public whether it is providing direct care, teaching or overseeing nursing practice.” Nursing has been found to be the most trusted profession in the regard to patient safety (Silva & Ludwick). Nurses are given trust “by the public and common themes related to infection control in order to encourage ethical thoughtfulness and proactive ethical action” (Silva & Ludwick, pp.2-3). Duties of nurses include not to work when sick and to protect themselves as well as patients from disease to monitor infection prevention practices (Silva & Ludwick).

Hospital acquired infections have many different consequences, such as: delay or prevent recovery, cause increased pain, discomfort or anxiety, increase the patients stay in the hospital which has financial losses, and cause psychological stress as a result of long periods spent in isolation. This is demoralizing for staff, patients, and their families which can lead to decreased public confidence in hospitals and doctors. According to Marquis and Huston (2009) infection prevention and control is essential in healthcare settings to reduce the risks in patients and healthcare workers. Nurses share responsibility with other healthcare professionals to reduce the risk of infection in patients. Patients have a right to be protected from preventable infection and nurses have a duty to safeguard the well-being of their patients.

Recent practice for Mercy General Hospital is to test for Methicillin-Resistant Staphylococcus Aureus (MRSA) upon admission to the hospital. Upon admission to the hospital, patients are swabbed in both nares for specimen culture. Centers for Medicare and medicate services (CMS) revised the Medicare hospital inpatient prospective payment system (IPPS) to initiate a prevision made by the deficit reduction act of 2005 (California Nurses Association, 2008). This Act is based on any complication such as hospital acquired infections, which increase Medicare payments (California Nurses Association). Effective October 1, 2008, hospitals would not receive additional payments for cases that have conditions that were not present upon admission and that could have been prevented (California Nursing Association).

The Nursing and Midwifery Council (NMC) code of professional conduct (Nursing and Midwifery Council, 2008) also states, you should act to identify and minimize the risk to patients and clients. Therefore protecting the patient is a priority and should be achieved to the highest standard possible.

The Nursing and Midwifery Council (NMC) Code of Professional Conduct (2008, para 4) outlines the nurses’ professional code, and also has implications for the role of the nurse in infection control, requiring them to protect patients and fellow healthcare workers from risks such as cross-infection. Clause 1 of the code informs nurses that, “you have a duty of care to your patients and clients, who are entitled to receive safe and competent care” (Nursing & Midwifery Council).

Many infections are acquired through the patient’s own lack of knowledge of the effectiveness of simple procedure, such as hand washing. Therefore, nurses have their role to fulfill in providing education for patients and their families to give them a greater understanding of the importance of the need for thorough compliance of these procedures. “Standard precautions are designed to define a high standard of routine care that will be effective in reducing the transmission of potential pathogens between patients or clients whilst protecting staff from pathogens carried by patients or clients” (Northern Health and Social Services, 2006).

Without proper hand washing techniques there are several ways of acquiring an infection within a hospital, two of them consist of: Cross (or exogenous) infection, which is when the infection has been spread from other people; either patients, visitors, hospital staff or even food and the surrounding environment. Whereas self (or endogenous) infection is when the infection is caused by microbes carried by the patient on their body, usually from septic areas. Compliance with universal precautions should be rigorous as to avoid spread of infection. For example, failure to change gloves between interactions with different patients can lead to the spread of disease. Ayliffe (2002) contended that the regularity of infection in hospitals; caused by multiple types of bacteria, could increase to epidemic amounts if aseptic and hygienic measures in the hospital collapsed.

Ethically, quality and safety is extremely important for patients, doctors, and nurses. One example, unfortunately, due to lack of proper hand hygiene is an outbreak that occurred of the SRSV (Small Round Structured Virus) or Norwalk-like virus. This particular virus is highly infectious and it is very important to wash your hands with soap and water after contact with someone who is ill and after using the toilet, especially if you are suffering from symptoms. An isolation room was set up for anyone who was query SRSV infected as the virus was transmitted through vomitus and faeces (Lopman, 2003).

Legal and ethical implications of not following hand hygiene policy may result in serious health complications for the patient. If a nurse is caught not following the proper hospital policy on more than one occasion it may result in a verbal warning, written warning, suspension, and even termination. According to Bryant (2005) “hospital staff should assume that their first obligation is to comply fully with all applicable laws. This enforceable responsibility falls squarely within the duty of care. Clarifying the totality of the duty of care is not easy for two reasons: (1) it has been defined over the years mostly in lawsuits filed by someone who was alleging the duty had been violated. (2) Every regulatory law enacted adds to the duty’s complexity” (p. 27).

Nurses are role models to the people with whom they come into contact with whether it is patients, visitors, students, or any healthcare workers. Therefore they should insist on compliance with basic procedures and practices as part of their job. They must assume responsibility for these practices as they are also held accountable under the NMC code of conduct and so should be at the forefront of efforts to prevent and control infections.

CONCLUSION

In conclusion, it has been demonstrated that infection control is a fundamental element of nursing practice. Nurses have a crucial role in preventing transmission of viruses, bacteria and fungi by simply washing their hands regularly. Hand washing is the most effective method in infection control and cannot be worked around.

REFERENCES

Ayliffe, G.A.J., Lowbury, E.J.L., Geddes, A.M., & Williams, J.D. (2002). _Control of hospital infection a practical handbook._ (3rd ed.). United Kingdom: Chapman and Hall Medical.

Biddle, C. (2009). Semmelweis revisited: Hand hygiene and nosocomial disease transmission in the anesthesia workstation. _AANA Journal_, _77_(3), 229-237.

Boyce, J., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm#top

Bryant, E. (2005). Ethical and legal duties for healthcare boards. _Healthcare Executive, 20_(4), 46-48.

California Nurses Association. (2008). Position statement on methacillin: Resistant staphylococcus aureus. Retrieved from

http://www.calnurses.org/swineflu/assets/pdf/mrsa_position_statement.pdf

Lalley, C., & Malloch, K. (2010). Workarounds: The hidden pathway to excellence. Retrieved from http://www.nurseleader.com/article/PIIS1541461210001242/fulltext

Lopman, B., Reacher, M., van Duijnhoven, Y., Hanon, F-X., Brown, D., & Koopmans, M. (2003). Emerging infectious diseases. Retrieved from http://www.cdc.gov/ncidod/EID/vol9no1/02-0184.htm

Marquis, B., & Huston, C. (2009). Leadership roles and management functions
in nursing: Theory and application. (6th ed.). Philadelphia: Lippincott-Raven.

Mercy General Hospital. (2006). Guidelines for hand hygiene.

Northern Health and Social Services. (2006). Infection control manual.

Nursing & Midwifery Council. (2008). The code: Standards of conduct, performance and ethics for nurses and midwives. Retrieved from

http://www.nmc-uk.org/Nurses-and-midwives/The-code/The-code-in-full/

Schmidt, N., & Brown, J. (2009). Evidence based practice for nurses: Appraisal and application of research. Massachusetts: Jones and Bartlett.

Silva, M., & Ludwick, R. (2006). Ethics column: What would you do? Ethics and infection control. _Online Journal of Issues in Nursing, 12_(1), 2-9.

RESEARCH STRATEGIES

The search strategy I used included Merriam Library at Chico State University, Pub med, Google Scholar and Medline. I also used basic search engines such as, Google Yahoo along with CDC, Joint Commission and American Nursing Association Website.

My search terms were narrowed down to peer-reviewed journals and “full text only” option. I did limit the years from 2005-2010. I used exploding techniques, nesting strategy, subject searching and Boolean operations (Schmidt & Brown, 2009, p. 94). The search terms used were; “Hand Washing,” “Hand Hygiene,” “Evidence based practice for hand-washing,” “Hand washing in health care setting,” “Nurses and Hand washing,” “Ethics and Managerial ethics,” and “patient Safety & Ethics.”