Patient participation in compliance with hand hygiene by health professionals: an integrative review

Participação do paciente na adesão à higiene das mãos pelos profissionais de saúde: revisão integrativa

Participación de los pacientes en la adherencia a la higiene de manos por parte de los profesionales sanitarios: una revisión integradora

Esta obra está bajo una Licencia Creative Commons Atribución 4.0 Internacional.

Healthcare-associated Infections (HAIs) are a worldwide public health concern and are defined by Ordinance 2616 of the Brazilian Ministry of Health as any infection acquired after patient admission to a health facility, manifested after forty-eight (48) hours after admission or after discharge, when associated with surgeries or invasive procedures.^1,2

In the United States of America (USA), in 2016 it was estimated that about 10% of hospitalized patients had HAI. The Brazilian Ministry of Health considers that incident reaches a proportion of 15% or more on this country. The Latin American Sepsis Institute (LASI) points out that annually 400,000 new cases are diagnosed and about 240,000 people die from HAIs³.

Aiming at the prevention of this problem, the Brazilian Health Regulatory Agency (ANVISA - Agência Nacional de Vigilância Sanitária) recommends the mandatory notification of the four types of HAI: primary bloodstream infection (BSI) associated with central venous catheter (CVC), ventilator-associated pneumonia (VAP), urinary tract infection (UTI) and surgical site infections (SSI)⁴ .

The simplest and most used strategy for HAI prevention is hand hygiene (HH), which consists of performing the procedure using appropriate technique and time, using water and soap or 70% alcoholic solution, in order to remove dirt and microorganisms⁵. Studies have shown that 99.9% of transitory colonization of the hands of health professionals was eliminated with the correct HH technique, following the steps recommended by the World Health Organization (WHO) guidelines⁶ .

However, the world literature reports a low compliance of health professionals with HH⁷ A study in Switzerland that aimed to improve HH compliance by professionals through performance feedback and patient participation found that less than 66% of professionals comply with the five moments of HH,. namely: 1) before touching a patient; 2) before a procedure; 3) after a procedure or body fluid exposure risk; 4) after touching a patient; 5) after touching a patient’s surroundings⁸.

In developing countries, the situation worsens. Research carried out in southern Brazil found that the compliance rate with the five (5) moments of HH was only 54.5% by health professionals working at a teaching and research hospital⁹. In southeastern Brazil, a study conducted in an Intensive Care Unit demonstrated that less than 43% of professionals performed HH adequately.¹⁰

Aiming at encouraging compliance with HH practices, the WHO implemented, in 2009, the multimodal strategy (MS), which is composed of five complementary and interdependent components of intervention, which have been proven to help in compliance with HH, both medium and short term, namely: 1) system change; 2) training & education; 3) monitoring & feedback; 4) reminders & communication; and 5) culture change.^8,11

It is worth noting that the components monitoring & feedback and culture change emphasize the importance of patient participation, which should be strongly encouraged in educational interventions based on the aforementioned MS. For this to occur, it is necessary to empower the user about the importance of HH by health professionals during the care provided. The WHO states that patient empowerment is a process in which they understand their role when receiving knowledge and skills from their health care provider, in order to understand the care process and ensure subsidies to intervene in the actions received⁸.

Given the proven effectiveness of HH to reduce HAI, low compliance of health professionals with this technique and the relevance of patient participation in actions that promote HH in health care environments, it was necessary to know: What is the impact of implementing educational strategies with patient involvement and participation in compliance with HH by health professionals?

The objective of this study was to verify the impact of implementing educational strategies with patient involvement and participation in compliance with HH by health professionals.

Study design

This study is an integrative literature review, which provides the introduction of experimental and non-experimental studies, in order to obtain a greater compression of the phenomenon. This type of study articulates information from theoretical and empirical literature, in addition to integrating several purposes, such as definition of concepts, review of theories and investigation of methodological problems of a specific topic.^{12, 13, 14}

The integrative review analyzes the current knowledge on a specific topic, being designed to identify, analyze and synthesize results of different studies on the same topic, aiming at the quality of care provided to patients.¹⁵ This study design is composed of six phases: 1) selection of research hypothesis or question ; 2) search strategy (establishment of inclusion and exclusion criteria, database and selection of studies); 3) categorization of studies (extraction, organization and summarization of data); 4) assessment of studies included in the review; 5) interpretation of results; and 6) synthesis of knowledge.^{12, 16, 17, 18}

Inclusion and exclusion criteria

Experimental, quasi-experimental or “before/after” scientific articles, which used an educational intervention to improve compliance with HH by health professionals, including patient participation, published in English, Spanish or Portuguese, from 2009 to 2019, were included. This period of time is justified by the year of dissemination of MS for HH by the WHO.

Theses, dissertations, studies in which the method was not adequately described, carried out only with health professionals, or which were not fully available were excluded.

Search strategies and data organization

Literature searches were conducted from April to July 2019. Primary studies were searched in the following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Latin American and Caribbean Literature in Health Sciences (LILACS), Current Nursing and Allied Health Literature (CINAHL), SCOPUS and Web of Science (WOS).

To guide the study, the PICO strategy (Participant, Intervention, Comparison and Outcomes)¹⁵ was used in order to identify in the texts the answer to the following question: What is the impact of implementing educational strategies with patient involvement and participation in compliance with HH by health professionals?

To ensure a thorough search, the Health Science Descriptors (DeCS), Medical Subject Headings (MeSH), uncontrolled descriptors (keywords) and the CINAHL Subject Headings were defined. The following DeCS, MeSH and CINAHL Subject Headings used were: health education, hand hygiene, patient participation, handwashing. The keywords used were: multimodal strategy, in addition to synonyms found on the DeCS and MeSH websites. Boolean operators AND and OR were used, in order to allow intersection and union between descriptors and keywords.

A total of 4857 articles were identified in the databases, as shown in Figure 1. These articles were initially organized using Clarivate EndNote Online, whose program facilitated the process of removing duplicates and articles that did not correspond to the period adopted for this study. This resulted in 1,988 duplicate articles and 894 that did not fit into the period adopted for this review.

Data were systematized using a guide called Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) for the categorization of studies. Figure 1 outlines the main steps taken, whose outcome met the inclusion of eight studies.

Figure 1
PRISMA flowchart for included studies

After search refinement using the PRISMA tool, the final sample consisted of eight (8) articles. The selected studies resulted in four (4) WOS studies, two (2) MEDLINE database studies, and two (2) Scopus studies. Data regarding educational interventions and study results are presented in Chart 1.

Chart 1
Synthesis of key information from the eight (8) articles included in this integrative review, Brazil, 2019

Note: MS: multimodal strategy; HH: hand hygiene.

Participants in the interventions were composed of nursing, medical and other health professionals who worked predominantly in adult Intensive Care Unit (ICU), medical clinic, emergency, pediatric clinic and surgical clinic sectors. The studies also involved patients admitted to tertiary care clinics who stayed at least three days in the health facility, as well as their caregivers or family members, when applicable.

In 62.5% of the studies, MS was used contemplating its five (5) components and patient participation stands out as a member of the fifth component “culture change”. In 25% of the articles, patient participation was included in the proposed interventions, and in 12.5% of the articles, patient participation was the only intervention performed.

As shown in Chart 1, the most used strategy was continuing education with patients, giving them the autonomy to question health professionals about HH in the moments before touching them, handling care equipment (e.g., infusion pumps, catheters and probes, mechanical ventilator, among others) and before touching objects placed in patients’ vicinity.

In all studies included in this sample, both patients and their caregivers and family members were trained to perform the correct HH, highlighting its importance due to the high rates of infections in the selected institutions, aiming to reduce HAIs, making them protagonists of their security process.

Three of these studies pointed out that patients are intimidated by questioning the health team, reporting that they are not comfortable in questioning their caregivers about their work tasks.^{7, 21, 25} In these studies, health professionals were composed of a multidisciplinary team, with the largest presence of physicians, nurses and nursing technicians.

However, the articles showed an increase in the HH rate by health professionals after the intervention was carried out using patients as part of the educational strategy.

HAIs represent a major global health problem, and their control is relevant both in developed and underdeveloped countries, as they generate a high cost for health institutions, since treatment is costly and can often be ineffective. Moreover, it causes harm to both the patient and the health professional, as both are susceptible to contamination by pathogenic microorganisms.²⁶

The steps that comprise MS to achieve HH actions are done through the change in the system, which concerns the institution’s infrastructure changes to ensure that health professionals can sanitize their hands and an organizational culture of installed safety, transversal to professionals, patients, direct supervisors and superiors. The favorable institutional safety climate is guided by the management responsibility to create an environment that facilitates professionals’ awareness and promotes positive perceptions of patient safety, ensuring HH improvement as a priority at all levels of health care.^27,12

In that regard, an essential part of this process is professionals’ education and training, through training and regular and permanent training on the implementation of the proper HH technique, contemplating the five (5) moments proposed by the WHO.²⁷ Through health education activities, the multidisciplinary team motivation also becomes viable, making them perform local actions that reinforce HH as a fundamental measure for HAI prevention and control and feel that they are protagonists in this process.²⁸

Thus, it is necessary that professionals and patients have technical knowledge about the correct mode of HH so that they can excellently comply with practice aimed at reducing HAIs. Note the importance beyond a health education activity, but as an artifact to optimize new practices and search for quality of care by both.²⁸

Based on the above, it is necessary to implement this theme in the training process of health professionals, as there is a need for technical and scientific development of this theme through the use of active methodologies, in order to emphasize the importance of HH.²⁹

The assessment and feedback component comprises monitoring the changes that have occurred, from monitoring HH practices to infrastructure, verifying whether educational interventions were effective in improving compliance. On the other hand, reminders in the workplace are instruments used to highlight the indications and importance of HH, performance of the appropriate technique and procedures, in places with greater circulation of professionals.³⁰

The aforementioned studies that make up the sample of this review showed the importance of patient participation as part of safe care and a favorable institutional safety climate, since compliance with HH was significantly improved with interventions that included patient empowerment.

Observational research in a specialized pediatric hospital in the Brazilian Midwest showed a considerable increase in HH by health professionals after the implementation of the five (5) components of MS after the implementation of the five (5) components of MS together with patient participation”.³¹

In the same way, a study carried out in Switzerland with health care professionals from a hospital in Geneva, aiming at improving compliance with HH by these health professionals, showed that patient involvement was effective in compliance with HH, proving to be statistically significant (p<0.04), increasing compliance with HH from 66% to 77% after the implementation of the educational strategy⁷.

Exploratory qualitative study, carried out in Porto Alegre to understand the perception of family members and caregivers in relation to patient safety, reinforced the need and relevance of training professionals to include the family, in order to promote safe care.³²

Educational strategies aimed at patient safety require effective communication between professionals and health services. Communication failures can affect the quality of services, resulting in incidents, errors and damages, such as medication administration errors that can be avoided with efficient communication between work team memebrs.^{33, 34, 35}

Institutions and health professionals need to ethically commit to improving communication, to ensure and preserve safety, integrity and respect for patients, coworkers and their own rights as professionals and citizens.³⁶

It is noteworthy that, in Brazil, the Resolution of the Collegiate Board of Directors (RDC) 63/2011 was established in 2011, which provides for the Requirements for Good Operating Practices for Health Services. In Article 8 of this RDC, it is established that a health service must institute strategies and actions aimed at patient safety, including “guidelines to encourage patient participation in the care provided”.³⁷

Based on the above, it was observed in this study that patient participation has a positive influence on compliance with HH by health professionals, although many patients are still intimidated by questioning the health team about performing the technique. The results showed that the main obstacle to this effective communication between patients and caregivers is the fact that users believe that this questioning or assessment of professionals’ practice can interfere with their care process.^{20, 21, 25}

In the same way, it is necessary to involve patients as active subjects in promoting improved compliance with HH of health professionals, as this is a useful and promising educational strategy, which should be part of the safety culture of health institutions.

Patient participation as a unique form of intervention is not an effective and long-lasting strategy for compliance with HH. WHO recommends that it is necessary to use several actions to address institutional obstacles and established behavioral cultures.^37,38 Cultural changes do not occur quickly and spontaneously, so they need to be permanent and always re-assessed⁸.

The present review showed that health education with patient participation has been shown to be effective in raising and maintaining the compliance rates with HH. Innovative methods with the inclusion of patients should replace conservative behaviors, in order to empower the subjects and keep them active in their care process.

Educational strategies that used patient participation and involvement in HH promotion by health professionals proved to be effective for greater compliance of health professionals with this essential technique. Thus, the interventionist strategies described here can support patient involvement in future actions aimed at improving HH in health facilities.

However, the lack of studies carried out in the Brazilian territory is highlighted, demonstrating the need for further discussion and application of MS components in health establishments, since compliance with HH is considerably lower than recommended and infection rates related to health care show worrying rates.