Importance Of Hand Washing

The intention of this assignment is to demonstrate an understanding of the art of reflection and the purpose of reflective practice within midwifery. The assignment is based upon a significant incident drawn from a clinical situation experienced on a busy maternity ward. The clinical aspect to reflect upon is the importance of hand washing compliance within a hospital environment between patients. Cooper et al (2004) state that there is awareness throughout the NHS that control of MRSA within the healthcare environment is vital to the continuation of the NHS. Infection control is vitally important, particularly on maternity wards due to the risk of
infection being transmitted from woman to baby (Pratt et al, 2001).

This reflective assignment will discuss the suggestion by Pratt et al (2001) along with my experience to the scenario in not entirely putting my expertise on the subject into practice, which impacted on my performance. The role of the midwife is of utmost importance when ensuring patient safety by decreasing the risk of cross contamination and infection. As a result, my feelings and methods of practice will be discussed along with my mentor’s reaction and help offered when in a situation where hygiene was overridden by changing circumstances. In relation to the NMC (2009) pseudonyms will be used to promote patient confidentiality.

Donald Schon (1983) refers to reflective practice as learning from experience; as reflective practice in midwifery is associated with the progress of quality in care, inspiring personal and professional growth allowing theory and practice to work alongside one another. Ralston (2005) suggests that if student midwives are able to establish the process of reflection effectively, it has the potential to aid personal knowing, allowing students to recognise their own needs, values and beliefs in order to understand an incident. 2.0 Findings

This assignment will follow John’s (1995) model of reflection referring to subject heading consisting of the Aesthetics, Empirics, Personal, Ethics and Reflexivity in order to concentrate and discuss in depth the scenario surrounding my actions relating to hand hygiene. The first reflective cue to be discussed will be the aesthetics. 2.1 Aesthetics:

Aesthetics as referred to by Johns (2000) is an interpretation of one’s actions based upon thoughts and emotions within a situation. I felt confident in caring for women postnatally. I had developed a good rapport with Sarah, confident in the knowledge that if a deviation from the norm arose. The atmosphere was open and conducive to communication, and I felt keen to demonstrate my ability to undertaken a postnatal examination correctly. Due to my assertive nature at this time, my body language conveyed a sense of warmth and welcoming, I felt ready to take charge of the situation, not wanting to be huddled behind my mentor exuding uncertainty.I drew back the curtain, with consent, displaying an atmosphere of happiness and joy.

Kerry lay on the bed, watching her new born with obvious awe. Her partner John seemed overwhelmed with paternal feeling, looking on with affection. The atmosphere was relaxed and both parents were at ease. I introduced myself to establish my intentions and purpose. I asked questions to develop a clear picture of Kerry and her surroundings. By familiarising myself to the situation, I felt unperturbed, knowing that my body language was open to any concerns Kerry may have wished to discuss. I asked Kerry in reassuring tones if I could undertake a postnatal examination on her baby. In order to maintain the calm aura, I explained to Kerry what the examination would entail. I proceeded to wash my hands, knowing it has long been a significant method of reducing the risk of infection as mentioned by Rhee, (2008). I began the examination in more depth beginning to feel slight anxiety, knowing Sarah would have high expectations on my performance.

Upon examination I realised that the baby’s left eye was slightly congealed with sticky white mucus. I did not want Kerry to be alarmed with my findings, instead of acting alarmed, I addressed the situation carefully, realising that any exclamation would have induced a sense of panic. I addressed Sarah calmly to examine the left eye. Rather than drawing a potentially incorrect conclusion I felt it best to rely on Sarah’s greater clinical knowledge. I didn’t want to make false assumptions regarding infection, which would cause unnecessary panic. Noticing Kerry’s reaction to Sarah examining the baby’s eye a second time, she become obviously distressed, displaying panic and apprehension, seeking clarification. She began to fidget and bite her bottom lip, displaying anxiety. Her partner moved closer to ease Kerry’s disquiet, and the tense atmosphere permeating the room. Realising my role of care to Kerry and acting in accordance to the NMC (2008) I had a duty to be open and honest. I asked Sarah what her findings were. Addressing Kerry and myself, Sarah explained calmly and compassionately that there was no real concern, and that it is a common symptom which can arise in some new borns.

In an act of synchrony both Kerry and John exhaled with relief. Demonstrating my knowledge, I discussed how to bathe the eye effectively. Sarah was satisfied with my explanation, resulting in me feeling a sense of achievement that I had provided useful knowledge. I began to ask questions relating to her well-being following birth. Kerry stated with concern that her stitches in the perineum were causing her slight discomfort. With consent I asked Kerry to lay on her side for me examine the area. Sarah placed a halting hand on my shoulder. I was unsure why and began to feel the stirrings of embarrassment and my hands became clammy with worry. Sarah instructed me to observer her ways of practice. I could feel my confidence draining, the atmosphere changed for the worse, and I wanted to retreat internally. I observed and immediately realised my mistake, Sarah proceeded to again wash her hands before coming into contact with Kerry.

At this point I felt foolish, knowing I could have jeopardised Kerry’s health by not decontaminating my hands after handling her new born who may have had an eye infection. Sarah stressed the importance of hand hygiene between each patient. I explained that due to being distracted by my new found confidence, I had made an obvious oversight by not remembering basic hand washing protocol between mother and baby. I felt let down by my own mistake allowing my professional standard to slip regarding hand compliance within the situation. Following on from the aesthetics section the empirical knowledge will be discussed and its relevance to the scenario experienced. 2.1 Empirics:

Empiric is a theory of knowledge which explores those aspects of scientific knowledge that are closely related to experience (Johns, 2000). Pratt et al (2001) recognizes that hand washing is crucial because infection and bacteria is often transmitted from patient to patient via the hands of practitioners. This was the message Sarah was highlighting to me in the scenario that serious consequences could have arisen due to my error. Pratt et al (2001) asserts that practitioners have long been aware that effective hand compliance cuts infection rates and more importantly saves lives, this is the reason behind Sarah feeling so strongly toward her patient care and safety by not allowing me to undertake the examination until I had realised the importance of hand compliance. Pittet et al (2004) agrees that hands are the highways to the transmission and spread of bacteria that causes disease and potentially the demise of a patient. However, according to current research, several practitioners fail to practice sufficient hand hygiene on a regular basis (Suchitra and Lakshmidevi, 2007). ]

WHO (2006) puts forth that ‘clean care is safer care,’ a slogan that some practitioners fail to recognise. Studies conducted by Centres for Disease Control and Prevention (2006) found that 60% of practitioners failed to adhere to the recommendations of hand compliance between patient contact and procedures. These findings emphasise that not only students fail to adhere to hand washing regulations which I demonstrated in the scenario. Siegel (2004) studied contamination levels of practitioner’s hands before and after direct patient contact. The research found that the number of bacteria recovered from fingertips ranged from 0-300 CFU.

Based on these findings, Kerry could have been subjected to potential harm as a result of my lack of regard to hand washing regulations. Bjerke (2008) stated that midwives who repeatedly failed to follow hand washing guidelines could face dismissal under new regulations. This highlights why Sarah stressed the importance in order for me to grasp the concept that failure to hand wash cannot not only result in harm to patients but could lead to the afore mentioned consequences. A study conducted by Jumma (2005) within a busy ward discovered for hand washing to be carried out effectively, a significant rise of 15% in staffing would be required for the time spent adhering to recommended guidelines.

The Department of Health (2005) also recognized this as an issue identifying further barriers to good hand hygiene which included poor knowledge of infection control, time pressures and poor techniques. However, a study conducted Ward (2007) reported a sustained increase in hand hygiene, which encompassed a number of intervention tactics likely to change hand hygiene behaviour such as provision of alcohol hand rub, information to visitors on using hand rub on entering the ward and feedback on practice, as was clearly demonstrated by Sarah correcting me. Masterson et al (2002) recognised improved compliance by 20% through the use of effective workshops underpinning the importance of hand washing. Lewis (2004) identified that high quality care cannot be taken for granted therefore promoting hand washing aims to reduce infection and cut figures associated with maternal death. Redshaw et al (2006) emphasises that each practitioner must act as an advocate for one another by prompting hand compliance to promote patient safety as Sarah had done so effectively on my behalf, it’s the role of the midwife to ensure each woman under their care are not subjected to harm via the risk of cross contamination (Aiell, 2002).

The Department of Health (2007) identified initiatives such as specialist ultraviolet light based training kits to illustrate to practitioner how easy it is to not decontaminate efficiently. Also recognising a variety of resources available along with guidelines; poor compliance is therefore based upon lack of competence on behalf of each individual who fail to practice appropriately (Department of Health, 2007). Recognition by Aiell (2002) suggests that protective equipment should also be worn to stop infection passing between practitioner and patient. It is also further suggested that gloves should act as an additional barrier, not instead of. My experience emphasises how easily I was distracted from adhering to these methods, fortunately I was prevented from causing serious harm, highlighted by the surrounding literature. The assignment will now discuss the personal aspect relating to the scenario. 2.3 Personal:

Johns (2000) highlights that the personal allows practitioners to realise their action and to suggest ways of acting differently to enhance better practice within a situation. Via reflection, I had several questions to ask myself regarding the underlying factors motivating my behaviour within the situation. I recognise the importance of efficient hand washing compliance as mentioned by the National Audit Office (2004) that hand washing is a necessary aspect of care and is the single most effective control behaviour that prevents the spread of infection and bacteria. I ensured I adhered to the guidelines before coming into contact with Kerry’s baby but unfortunately failed to do so with Kerry. I behaved in this manner due to being overridden by my confident explanation regarding appropriate eye bathing procedure a to reduce the chances of infection.

However, due to my actions I was not reducing the risk of infection between mother and baby; I was increasing the risk of an infection being developed. I should have emulated Sarah and proceed to decontaminate my hands again to decrease the risk of cross contamination via carrying infected material from the baby’s eye to an area that posed concern to Kerry. Upon reflection I am grateful that Sarah intervened, otherwise the danger of the situation could have been heightened, possibly leading to serious consequences regarding cross contamination. I now recognise the difficulty of acting appropriately after an error has arisen. Undertaking personal reflection I feel I can now
identify myself a being foolish by being unable to comply and to be fully aware of the crucial importance of hand washing. Women centred care is at the heart of Midwifery and I should have established this within my scenario to prevent such practice from occurring (Care Quality Commission, 2009). 2.4 Ethics:

John’s (2000) refers to ethics as identifying what is right and wrong and being dedicated to act on this basis. As a student midwife and an autonomous practitioner I must consider my actions carefully. In relation to the NMC (2008) it is important to make the care of all women the first concern, whilst promoting wellbeing and safety. I had a duty of care as a student midwife to ensure that Kerry and her new born received a high standard of care within my limitations (Edwards, 2006). Boomgaarden et al (2003) refers to beneficence as a means of doing good and positively helping a person. I acted in a beneficent manner, before undertaking any examinations within scenario I ensured that I gained Kerry’s consent, rather than assuming a consent was a given.

By ensuring consent before each examination I was facilitating Kerry’s autonomy by assisting her to have a degree of choice and control. In my beneficent nature I ensured that I adhered to necessary guidelines (DOH, 2008) before coming into contact with Kerry’s baby, by doing so I was limiting the risk of cross infection being imposed on the baby. Furthermore, by seeking to clarify my findings with Sarah in relation to the sticky eye, I made sure not to cause any undue anxiety, by deferring to Sarah to provide her clinical expertise in the situation, rather than myself providing false assumptions. Fry et al (2002) advocates that a deontological theory is based on people following their duties of care, further stating that deontologist will always keep their promises and produce consistent decisions as a result on an individual’s duties.

I believe I adapted a deontological approach with Kerry, because I focused only on her individual concerns and problems such as providing advice on eye bathing procedures and perineum care. Midwives must take into account moral values and judgments (Jones, 2004). Due to Sarah’s presence I was prevented from making a reckless mistake in accordance to hand compliance by putting Kerry in a vulnerable position due to not decontaminating my hands after examining her baby. I could have subjected Kerry to harm; however, because my error was laid out clearly, patient safety was promoted. As a result of effective communication regarding the scenario and by my actions being halted I was prohibited from acting in a maleficent manner. Reflexivity will be the final reflective cue to be discussed. 2.5 Reflexivity:

Reflexivity enables practitioners to recognize and resolve contraindications between aims and practice, with the intent to achieve effective work (Johns, 2000). Via the reflective process it has been both beneficial and valuable to my learning within practice. The scenario has developed my knowledge in great depth due to Sarah stressing the importance of hand hygiene after the situation had taken place. From this I now understand that hand washing procedure should be undertaken with gravity given the risk it contributes to patients (Jumaa, 2005). With reference to Kerry I have learnt never to act without thinking out the consequences of my actions. I now realise why I was halted by Sarah and to effectively learn from her methods of practice, by undertaking the process of hand washing between each patient.

This assignment on reflection has enabled me to further undertake my own personal hand compliance which benefits both women and babies under my care. Therefore my changes in the ways of my thinking have taken place as a result of reflection which will impact on my practice in future. Reflection has allowed me to research the topic in depth and actively seek out more knowledge and to learn from my own mistake when performing an examination similar to Kerry’s. This assignment has equipped me with awareness that I must be more rigorous with hand compliance when faced with a similar situation in future practice and that hand decontamination is vital between patients not just before the first patient. Understanding our emotions and the reasons why we feel the way we do, allows us to explore our actions and truly learn from them. Reflecting on the situation has helped me to be certain that the actions of Sarah on my behalf were vital and stressing the relevance of hand compliance was crucial to my future practice to prevent such error from arising again.

3.0 Appendix:
Having just received handover during the morning shift my Mentor Sarah decided that it would be a good experience for me as a student to continue caring for the women postnatally to enhance my development and knowledge. The postnatal wing was very busy and I knew it was my opportunity to demonstrate my competent awareness regarding postnatal examinations. Debbie and I approached bed three ready to undertake a routine postnatal check up on both mother and baby. The room was surrounded by cards and an array of balloons congratulating the couple on the arrival of their baby. I introduced myself to Kerry, the mother and also with the same enthusiasm I greeted her partner John, who was lavishing affection over their baby.

I was greeted with enthusiasm and took it upon myself to discuss and provide an explanation of both postnatal examinations and what the procedure entailed. Before undertaking the postnatal on the baby I decided to ask questions relating to the baby’s feeding pattern. Kerry explained that her baby was being artificially feeding every three to four hourly and consuming between twenty to thirty ounces at each feed. Happy with my findings I was now prepared to undertake a top to toe examination to ensure the baby’s well-being and to identify any deviations that may arise. Knowing the importance of consent I always ensured that Kerry was happy for me to proceed. I was aware of the risk of contamination via my hands which could pose a high risk of infection if not decontaminated effectively before contact with the baby. Before the examination I washed my hands. Whilst undertaking the examination I realised a slight deviation which consisted of white mucus surrounding the left eye.

At this point, realising my student status and only being a first year I looked to Sarah for advice on my findings and to provide Kerry with the adequate knowledge that surrounded identifying an infection and the action plan that followed. Realising the outcome of the baby’s eye and that it posed no significant risk, I decided with Sarah’s approval to provide advice and knowledge on bathing the eye using cotton wool and cooled boiled water to limit the chances of infection arising. Sarah was pleased with my explanation as was Kerry; therefore this had lead my confident level to soar. Realising that Kerry also required a routine postnatal examination to establish her well-being after labour. I asked questions under the direct supervision of Sarah and with consent read her labour notes to familiarise myself with her experience of labour. The notes stated that Kerry was a primipgravida and during labour used both entonox and a 100mg of pethidine as methods of analgesia. I also read that due to a prolonged second stage and fetal deceleration presenting the midwife in charge decided to undertake an episiotomy in the best interest of both woman and baby.

Having undergone this procedure Kerry requires suturing within the perineum. I enquired regarding the healing process of the perineum and Kerry stated that it was posing her concern due to the pain and discomfort it caused whilst sitting in certain positions and micrition. By my new found confidence and promoting patient well-being I decided to observe the healing process. Pleased that I was able to demonstrate my confidence and knowledge to the situation I asked Kerry to lie on her side in order to view the premium. However before I could come into contact with Kerry my actions were immediately halted. Sarah took charge of the situation and firstly made her way over to the sink and applied gloves. Sarah explained that the area was slightly bruised and swollen and that it would require a couple of weeks to heal entirely and that analgesia would be required as methods of soothing the pain. After the examination had taken place and Sarah and I were back in the office, Sarah stressed the importance of hand washing between each patient and the dire effects it can cause if not undertaken sufficiently. This assignment will concentrate on the importance of hand washing within a clinical environment and the how vital it is to decontamination between each patient under your care.

5.0 Reference List
Aiell, AE. (2002) ‘What is the evidence for a causal link between hygiene and infections?’ Lancet Infection Diseases, 2:103-110. Bjerke, NB. ‘The evolution: Hand washing to Hand hygiene guidance.’ Critical Care Nursing Quarterly, 27:295-307. Boomgaarden J., Louhiala P. and Wiesing U. (2003) Issues in Medical Research Ethics – A Workbook for Practitioners and Students. New York: Bergman Books.

Centers for Disease Control and Prevention (2002) Guidelines for hand hygiene in health care settings: Recommendations of the health care infection control practices advisory committee and the hand hygiene task force. Morbid Mortal Wkly Rep, 51(RR16): 1 – 45.

Cooper, B. (2004) ‘Preliminary analysis of the transmission dynamics of
nosocomial infection: Stochastic and management effects: Journal of Hospital Infection, 43, 2, 131 – 147.

Care Quality Commission (2009) Guidance about compliance. Essential standards of quality and safety, Care Quality Commission, London.

Department of Health (2005) Essential steps to safe, clean care. Department of Health, London.

Department of Health (2007) Maternity Matters: choice, access and continuity of care in a safe service. Department of Health. www.dh.gov.uk/publications.

Department of Health (2008) High Quality Care for All, NHS next stage review final report, Department of Health, London. Edwards, S.D. (2006) Nursing Ethics: A Principle Based Approach. London: Macmillian Press.

Fry S. and Johnstone M. (2002) Ethics in Nursing Practice: A Guide to Ethical Decision Making. 2nd Edition, Oxford: Blackwell Publishing Company.

Johns, C. (2000) Becoming a Reflective Practitioner. Oxford Blackwell Publishing.

Jones, S.R. (2004) ‘Ethics and the Midwife,’ in Henderson, C., Macdonald, S. (eds) Mayers Midwifery: A Textbook for Midwives. 13th ed. Edingburgh: Bailliere Tindall, pp. 1133 – 1141.

Jumma, PA. (2005) ‘Hand hygiene: Simple and complex.’ International Journal of Incetions Diseases, 9:3-14

Lewis G (2004) Confidential Enquiries into Maternal and Child Health. Why Mothers Die. The Sixth Report of the United Kingdom Confidential Enquiries into Maternal Deaths in the United Kingdom.London. RCOG Press. 2004. www.cemach.org.uk

Masterson, RG., Teare, EL. (2002) ‘Clinical Governance and infection control
in the United Kingdom,’ J Hosp Infect, 47: 25 – 31.

National Audit Office (2004) Improving Patient Care by reducing the risk of hospital acquired infection: A progress report. Report by the controller and auditor general 876 Session. Stationery Office, London.

Nursing and Midwifery Council (2008) Midwives Rules and Standards. London: Nursing and Midwifery Council, 2008.

Nursing and Midwifery Council (2009) An NMC guide for students of nursing and midwifery. London: Nursing and Midwifery Council 2009.

Pittet, D., Hugganet, S., Harborth, S, et al (2000). ‘Effectiveness of a hospital wide programme to improve compliance with hand hygiene. Lancet 356:1307 – 1312. Pratt, RJ., Pellowe, C., Loveday, HP., et al (2001). ‘The epic Project: developing national evidence-based guidelines for preventing healthcare associated infection.’ J Hosp Infect 47: S3 – S4.

Ralston, R. (2005) Supervision of Midwifery: a vehicle for introducing reflective practice. British Journal of Midwifery, vol 13, no 12 792 – 796.

Redshaw M, Rowe R, Hockley C, Brocklehurst, P. Recorded delivery: a national survey of women’s experience of maternity care 2006. National Perinatal Epidemiology Unit. Oxford; NPEU; 2007. ISBN 978 0 9735860 8 0. www.npeu.ac.uk

Rhee, V. (2008) ‘Maternal and birth attendant hand washing and neonatal morality in Sothern Nepal.’ Archives of Pediatric and Adolesecnt Medicine, 162 (7): 603 – 608.

Schon, D. (1983) The Reflective Practitioner: How professionals think in action. Avebury Press: Aldershot.

Siegel, M., Doner, L. (2004) ‘Marketing public health:’ Strategies to promote social change, 2nd (ed). Jones and Bartlett Publishers.

Suchitra, JB., Lakshmidevi, N. (2007) Hand washing compliance – Is it a Reality? www.ojhas.org/issue20/2006-4-2.htm.

World Health Organisation (2006) Guidelines on Hand hygiene in healthcare improving adherence to hand hygiene practice: A Multidisciplinary Approach. Who Press.