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Nurse Education Today 97 (2021) 104719

Available online 11 December 2020 0260-6917/© 2020 Elsevier Ltd. All rights reserved.

Impact of the fluorescent concretization intervention on effectiveness of hand hygiene in nursing students: A randomized controlled study

Öznur Gürlek Kısacık a,*, Yeliz Ciğerci b, Ülkü Güneş c

a Faculty of Health Science, Fundamentals of Nursing Department, Afyonkarahisar Health Science University, 03200 Afyonkarahisar, Turkey b Faculty of Health Science, Surgical Nursing Department, Afyonkarahisar Health Science University, 03200 Afyonkarahisar, Turkey c Faculty of Nursing, Ege University, 35030 Bornova, İzmir, Turkey

A R T I C L E I N F O

Keywords: Glo germ Hand hygiene Hand hygiene belief Hand hygiene skill Nursing students

A B S T R A C T

Background: Hand hygiene is the most effective and simplest infection control method but there is a considerable amount of evidence that shows hand hygiene skills of nursing students should be improved. Nursing education plays an important role in giving nursing students the necessary knowledge, beliefs and teaching and improving basic hand hygiene skills. An effective learning method that enables students to understand both the practical skills and the underlying theoretical principles should be used in teaching hand hygiene. Objectives: The aim of this study was to compare the effects of a fluorescent concretization intervention and conventional education on improving the hand hygiene beliefs and skills of nursing students. Design and setting: This double blinded pretest-posttest randomized controlled trial was carried out from January 1 to June 1, 2019 with the participation of 126 nursing students in a faculty of health science in a state university in Turkey. Methods: The participants were randomly assigned to an intervention group (n = 63), receiving education with a fluorescent concretization intervention, and a control group (n = 63) receiving conventional education. Results: There was a significant difference between the intervention and control groups in terms of the total post- test hand hygiene belief score (p = .016 effect size(r) = 0.214). The final handwashing skill score of the students in the intervention group increased significantly for the seven regions of hands (p < .001 effect size(r) = 0.863). In addition, final handwashing skill score in the intervention group (20.62 ± 4.07) was found to be significantly higher than that of the students in the control group (12.57 ± 2.85) (p < .001 effect size(r) = 0.805). Conclusion: Hand hygiene training which includes visual concretization intervention with glo germ can be used as a useful strategy to improve nursing students’ negative beliefs about hand hygiene and to gain students to effective handwashing behaviors.

1. Introduction

There has been a notable increase in epidemics over the past decade around the world. Healthcare workers form the leading group that is affected by these epidemics and occupational exposures (Öncü et al., 2018). Hand hygiene (HH) is one of the most effective, simple and low- cost infection control procedures to prevent acquire or transmit of epidemic infections such as COVID-19 (Lotfinejad et al., 2020; WHO, 2020). On the other hand, hospitals are an environment where people come to seek treatment and recovery for their illness, however, many patients develop infections that they did not have before admission. Health care-associated infections (HAIs) are the most common

complication of hospital-based care, but are also an important patient safety problem (Labrague et al., 2018). These infections are responsible for a large portion of the costs in the health care system, and they are also an important cause of mortality and morbidity in inpatients (Al- Tawfiq and Tambyah, 2014; Badia et al., 2017; Fleischmann et al., 2016). The unclean hands of health personnel are an important factor in the transmission of the pathogens responsible for HAIs between patients. Although a major threat to patients’ safety, many HAIs can be prevented by properly performed hand hygiene. From the perspective of both healthcare staff safety and patient safety, HH is very important to pre- vent the transmission of pathogens and reduce the incidence of in- fections due to healthcare staff (Alshehari et al., 2018). Many studies

* Corresponding author. E-mail address: oznur.kisacik@afsu.edu.tr (Ö.G. Kısacık).

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https://doi.org/10.1016/j.nedt.2020.104719 Received 21 July 2020; Received in revised form 20 November 2020; Accepted 1 December 2020

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have shown that compliance with HH can reduce the transmission of HAIs, associated morbidity and mortality, length of hospital stay, and health care costs (Guest et al., 2019; Martínez-Reséndez et al., 2014; Thi Anh Thu et al., 2015).

Nursing students (NSs) are considered to be healthcare professionals in the course of their education. As a part of healthcare teams, they undertake a large part of the treatment and care of patients during their clinical practice. Because they are in direct contact with patients, they may be a means of transmission and cross-contamination of pathogens and can be infected with pathogens (Korhonen et al., 2019; Nasirudeen et al., 2012). Nursing education plays an important role in giving NSs the necessary knowledge, attitudes and beliefs to prevent HAIs, and teach- ing and improving basic HH skills. However, HH competency is a critical component and remains a major challenge for nurse educators (Kelcí- kova et al., 2012; Korhonen et al., 2019). Given the importance of HH education, the adequacy of the techniques through which the skills are taught, and their capacity to lead to effective and sustainable behavior is also significant (Konicki and Miller, 2016; Suen et al., 2019). Traditional teaching methods are insufficient for the knowledge being learned about HH to lead to long-term behavioral change (Lehotsky et al., 2015). Therefore, an effective learning method that enables students to un- derstand both the practical skills and the underlying theoretical prin- ciples should be used in teaching HH, with the aim of improving NSs’ necessary knowledge, attitudes and practices in this regard (Kelcíkova et al., 2012). Integrating theory and practice is an important aspect of learning effective HH practice during nursing education (Salmon et al., 2013). Students who understand the theory behind nursing actions may place more value on the connection between theory and practice, and be better able to translate their knowledge into practice (Korhonen et al., 2019).

In recent years, the use of a fluorescent solution shining under ul- traviolet (UV) light has become popular in teaching effective HH behavior and evaluating its effectiveness (Fishbein et al., 2017; Konicki and Miller, 2016; Suen et al., 2019). Glo germ, an UV fluorescent compound, is used to teach correct and effective handwashing and reinforce the handwashing habit. It provides a visualization of the contaminated areas of the hands under UV light and is an aid that re- inforces the need for more effective washing of hands and the adoption of correct handwashing. It has been reported that the use of fluorescent material in interventions to teach or improve HH is generally effective and that it can be used as an educational tool (Fishbein et al., 2017; Konicki and Miller, 2016; Suen et al., 2019).

1.1. Aim

The aim of the present study was to compare the effects of a fluo- rescent concretization intervention and conventional education on improving NSs’ HH beliefs and skills. Our hypothesis was that the NSs in the intervention group would have better beliefs and skills.

2. Method

2.1. Study design and setting

This study applied a double-blind, pre-test post-test randomized controlled experimental design. The study was conducted between January 1 and June 1, 2019 in the Department of Nursing in the Health Sciences Faculty of a University in Afyonkarahisar in the Aegean Region of Turkey.

2.2. Participants

One hundred and twenty six NSs who were students in the 2nd, 3rd and 4th years in the nursing department of the above-mentioned insti- tution in the 2018–2019 academic year, who had received theoretical and practical education on HH within the scope of the basic nursing

skills course, who had experience in clinical practice, and who gave their informed consent were included in the study. Power analysis was per- formed to calculate the required sample size for the study. The signifi- cance level was accepted as α = 0.05 while the effect size was accepted as d = 0.5. Accordingly, the minimum sample size for each group was calculated as 63 for a power of 0.90 (1-β). The power analysis was performed using the G-Power 3.1 software program. In order to elimi- nate the effect of academic achievement on the results of the study, the students were divided into three groups; high, medium and low level according to their academic records, and a total of 126 students (42 students in each academic level) were included in the study using the simple random sampling method. From the 42 students at each aca- demic level, 21 students were selected for the intervention group, and 21 students were selected for the control group using the simple randomi- zation method, so that each group contained 63 students. In the study, the control group consisted of students who received theoretical HH education (n = 63), while the intervention group consisted of the stu- dents who received the visual concretization of handwashing activity with an UV fluorescent compound (glo germ) together with the theo- retical training (n = 63). Fig. 1 shows a flow diagram of the steps in the procedure.

2.3. Data collection tools

2.3.1. Student information form This form contained questions on age, gender, year of education and

HH, as well as the participation of the NSs in extracurricular activities.

2.3.2. Hand hygiene belief scale (HHBS) This was developed by van de Mortel in 2009 to determine the beliefs

of individuals about HH. In the Turkish validity and reliability study conducted by Karadağ et al. (2016) and the final version of the scale consisted of 22 items. The score obtained from the scale ranges between 22 and 110; higher scores indicate more positive beliefs about HH (van de Mortel, 2009). In the Turkish validity and reliability study, the test- retest correlation coefficient was 0.66 and the cronbach’s alpha value was 0.76. In this study, the cronbach’s alpha value was found to be 0.73 for the HHBS.

2.3.3. Handwashing skill efficacy (HWSE) The efficacy of the handwashing skills of NSs in the intervention and

control groups was evaluated by observing the residues of fluorescent material on their hands under black-blue light (UV lamp) and in a black box, with a scoring method based on the community program Germ City and similar studies (Fishbein et al., 2017; Lusher, 2002). The evaluations were made by two independent observers who did not know which student was included in which group. In the laboratory environment where the evaluations were made, the working environment was kept dark in order to prevent any negative effects of day light when evalu- ating the residues of the fluorescent substances on the hands. The effi- cacy of the NSs’ handwashing skills were evaluated by observing the fluorescent material residues in the seven areas of the evaluated hand (finger tips, nails, palms, dorsum of hands, interdigital areas, thumb, wrist). They were scored as follows; very dirty = 1 point, dirty = 2 points, clean = 3 points and very clean = 4 points. The possible scores for handwashing skills range between 7 and 28, and higher scores mean that the handwashing skill is more effective. It has been reported that the dominant hand tends to be less clean than the other hand (Fierer et al., 2008). In this study, the dominant hands of the NSs were used to eval- uate the efficacy of their handwashing skills. For ambidextrous students, only the right hand was used for the evaluation. The Cohen’s kappa coefficient was 0.85 for the first handwashing and 0.83 for the last handwashing.

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2.4. Data collection and intervention

In order to ensure that the students in the intervention and control groups were not aware of each other, the data collection process of the NSs in the control group was completed first. Training interventions for the NSs in both the intervention and control groups were carried out in 18 sessions in the practice laboratory at the educational institution outside the NSs’ usual course and practice hours. The NSs were informed about the purpose and protocol of the study and that their participation

was voluntary. However, the NSs were not informed which group they were in. All the participants were asked to fill out the Student Infor- mation Form and HHBS, in order to obtain the pre-test data of the NSs. Then, the first handwashing practice was started to evaluate the HWSE of the students in both groups.

2.4.1. Control group Each student was asked to apply 2 ml of glo germ lotion containing

fluorescent material visible only under UV light to the entire area of

Fig. 1. Randomized controlled study flowchart.

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their both hands, to wait for 15–20 s to dry it, and then wash their hands with soap and water (first handwashing). The NSs were not informed about the properties used for the glo germ lotion and evaluation tech- nique in order to not affect their handwashing performance. In addition, no interventions were made on the NSs during handwashing. Seven regions of the dominant hands of the NSs were scored. In this way, the first data on the NSs’ HWSE were obtained. After this activity, only theoretical HH education was given to the NSs in the control group. The content of the theoretical HH education, which was delivered through a 45-minute long PowerPoint presentation to the NSs in both groups, was based on the World Health Organization (WHO) Hand Hygiene Guide (WHO, 2009), a literature review, and expert opinion. Four weeks after the training, the NSs in the control group were asked to fill in the HHBS for a second time, and thus the post-test data of the NSs were obtained. After obtaining the post-test data, the steps followed in the first hand- wash were applied again (final handwashing). Then the HWSE of the NSs was reevaluated by two independent blinded observers using the same method and the final data on the effectiveness of their hand- washing skills were obtained.

2.4.2. Intervention group All stages, including theoretical HH training, took place in the same

manner as the control group. After the theoretical training, for the NSs in the intervention group, an intervention phase was started using the UV fluorescent compound glo germ to visually concretize how effectively they had cleaned their hands. For this, visual feedback about their first hand washing performances was provided to the NSs by allowing them to see in the dark and under UV fluorescent light, the areas covered with glo germ that had been neglected in the first handwashing. After that, each student in the intervention group reapplied 2 ml of glo germ lotion to their hands, and applied the nine handwashing steps recommended by the WHO in theoretical training under the supervision of the re- searchers. Each student was allowed to re-examine their hands and to see the change to their hands in the dark environment and under UV fluorescent light after they had washed their hands correctly and effectively. Four weeks after the first handwashing, the post-test data on the HHBS were obtained and the evaluation of the effectiveness of final handwashing were performed in accordance with the control group procedure.

2.5. Ethical considerations

Ethical approval for the study was obtained from the Clinical Research Ethics Committee of the a university (Date/No:2018-69), and written permission was obtained from the administrators of the educa- tional institution where the study was conducted. In addition, the NSs participating in the study were informed about the objective of the study and their written and verbal informed consent was obtained. In addition The data were analyzed and reported in such a way that the participants cannot be identified.

2.6. Data analysis

The data analysis was performed using the SPSS version 22.0 Pack- age Program (Armonk, NY: IBM Corp.). Skewness-Kurtosis values and the Kolmogorov-Smirnov test were used to evaluate whether the data were distributed normally. The descriptive statistics of continuous var- iables in the study were shown with mean, standard deviation, mini- mum and maximum values, while descriptive statistics of categorical variables were shown by frequency and percentage. The Mann-Whitney U test was used in the independent group comparisons of the HHBS and HWSE scores of the NSs; the temporal differences between the HHBS and HWSE scores of the NSs were analyzed using the Wilcoxon Signed-rank Test. The r = (Z/(√Nobs)) formulation was used to calculate the effect size for the comparison of HHBS and HWSE scores of independent groups calculated using the Mann-Whitney U test. In addition, Analysis

of the effect size of the temporal differences between the HHBS and HWSE scores of NSs was performed with r = (Z/(√Npairs)) (https:// rcompanion.org/handbook/F_04.html; Lenhard and Lenhard, 2016). According to Cohen’s definitions, r value intervals is defined as r = 0.1 to 0.3: small effect; 0.3 to 0.5: intermediate effect; 0.5 and higher: strong effect (Cohen, 1988). An alpha level of p < .05 was accepted as statis- tically significant.

3. Results

3.1. Characteristics of the NSs

Characteristics of the NSs; The average age of the NSs in the inter- vention group was 21.02 ± 1.21 and the control group was 21.19 ± 1.55. The majority of NSs in both intervention (80.9%) and control (76.2%) groups were female. The majority of NSs in both groups had not attended previous extracurricular activities about HH.

3.2. HHBS scores of the NSs

The mean pre-test HHBS score of the NSs was found to be 84.10 ± 4.86 for the intervention group, and 85.12 ± 5.85 for the control group (Table 1). When the responses of the NSs to the positive items in the HHBS were analyzed, it was observed that the NSs in both intervention and control groups obtained the lowest mean scores (3.41 ± 1.17; 3.65 ± 1.24, respectively) for the item “I follow the guidelines of senior healthcare workers when deciding whether or not to perform hand hy- giene” (Table 2). When the mean post-test HHBS scores of the NSs were examined, the mean score of the NSs in the intervention group (88.37 ± 6.96) was significantly higher with small effect size than the mean score of those in the control group (86.38 ± 8.30) (p = .016; effect size(r) = 0.214 Table 1). In addition, while the mean post-test HHBS scores of the NSs in the intervention group increased significantly with intermediate effect size compared to their mean pre-test HHBS scores (p < .001; effect size(r) = 0.409). there was no significant difference between the pre-test and post-test scores for the HHBS for the control group (p = .557; effect size(r) = 0.049 Table 1).

3.3. HWSE scores of the NSs

In the first handwashing, the mean HWSE score of the NSs’ was found to be 11.75 ± 2.94 for the intervention group, and 11.73 ± 3.22 for the control group (Table 1). In the first handwashing, the areas where HWSE was insufficient were the wrist, thumb, dorsum of the hand, and the nails in both groups (Table 3). The mean final HWSE score of the NSs in the intervention group (20.62 ± 4.07) was significantly higher with a strong effect size than that of the NSs in the control group (12.57 ± 2.85) (p < .001; effect size(r) = 0.805 Table 1). In addition, the mean HWSE score increased significantly with a strong effect size for the seven hand areas in the intervention group (p < .001; effect size(r) = 0.863 Table 1).

4. Discussion

This study investigated the effects of visual concretization using an UV fluorescent compound in improving Turkish NSs’ HH beliefs and skills. The beliefs about the importance and necessity of HH are one of the significant factors that promotes compliance with HH procedures (Labrague et al., 2018; van de Mortel, 2009). Although our results show that the use of glo germ in NSs in the intervention group increased the HHBS scores compared to the control group, it was determined that the difference between the two groups had a small effect. Several studies showed that behavioral beliefs and intention as the significant pre- dictors of self-reported HH behavior (Limper et al., 2013; O’Boyle et al., 2001; White et al., 2015). Although beliefs about the importance and necessity of HH are considered to be a factor affecting HH behavior, it is reported that studies generally measured HH behavior based on

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behavioral intention and self-report only, rather than actual behavior (Khuan et al., 2020). On the other hand, van de Mortel reported that the theoretical framework of the HHBS is based on the concept that in- dividuals’ behaviors and beliefs about the consequences of their behavior are important variables that affect learning behavior (van de Mortel, 2009). Consequently, the value attributed to HH outcomes af- fects whether students learn this behavior effectively (Al Khawaldeh et al., 2015; Cruz and Bashtawi, 2016). A study conducted with Saudi NSs reported that HH practices are better in NSs who know that HH is an effective measure to prevent HAIs (Cruz and Bashtawi, 2016) A study conducted in Jordan showed that NSs’ beliefs about HH was an impor- tant determinant of their compliance with HH procedures (Al Kha- waldeh et al., 2015). Our findings showed that traditional HH training did not improve the beliefs of NSs in the control group, although there was a moderate improvement in HHBS score of NSs in the intervention group. Jeong and Kim (2016) reported that information alone is not sufficient to change beliefs about HH, and positive behavioral beliefs are needed to improve compliance with HH procedures. Traditional teach- ing methods are insufficient to properly implant concepts and maintain long-term improvement in HH practices (Fishbein et al., 2017). The use of visual aids in the HH education of NSs encourages their interest and understanding. The NSs in the intervention group saw how effectively washed their hands thanks to glo germ provided them with feedback about the results of effective handwashing. Diefenbacher et al. (2019) reported that feedback is a useful approach for improving HH. It has been emphasized that showing NSs the areas of their hands covered with fluorescent material, and informing them about microorganism coloni- zation on the surfaces, can be an effective educational tool to overcome the deficiencies in HH and improve attitudes towards it (Öncü et al., 2018; Škodová et al., 2015).

NSs learn about handwashing in the first year of their education and understand the importance of handwashing. Students who interact with patients during their clinical practice are expected to wash their hands correctly and with sufficient frequency (Avşar et al., 2015; Öncü et al., 2018). In this study, the results of the first handwashing practice showed that the NSs in both the intervention and control groups were not able to apply this basic skill effectively. The studies conducted to examine the HH behaviors of NSs have revealed that their HH skills should be improved (Avşar et al., 2015; Ceylan et al., 2020; Kingston et al., 2018;

Korhonen et al., 2019; Öncü et al., 2018). The findings related to the NSs’ final handwashing practice showed that the training given with the visual concretization using glo germ in the intervention group signifi- cantly improved the mean HWSE score of the NSs, and led to a signifi- cant difference with a strong effect between the HWSE scores of the intervention and control groups. These findings suggested that the visual feedback provided by applying glo germ increased the HWSE of the NSs and had a positive effect on raising their awareness about previously neglected areas during handwashing. The results of several studies support our suggestion that providing visual feedback by using a fluo- rescent compound may be a useful option in improving handwashing ability and HH compliance (Fishbein et al., 2017; Konicki and Miller, 2016; Suen et al., 2019). In addition, The lack of a sufficient improve- mentin the total HWSE scores of the NSs in the control group, supports the fact that traditional teaching methods are not effective for devel- oping this skill and maintaining the desired behavior.

4.1. Limitations and strengths

Results obtained from the current study revealed that HH education intervention with Glo germ can provide significant improvement espe- cially in HH skills of NSs. However, these results are based on an assessment only four weeks after the education intervention. This study did not examine whether this improvement in students’ handwashing skills translates into longer-term behavioral changes. This is an impor- tant limitation of the study. Therefore, future studies should focus on evaluating the sustainable impact of HH education with Glo germ on handwashing skill. This is an interventional study which was conducted to improve the HH beliefs and skills of the NSs in a Health Sciences Faculty in the Aegean Region of Turkey. Therefore, the results obtained from the study can’t be generalised to other populations beyond those in this study. In this study, the evaluation of the effectiveness of the NSs’ HH skills assumed that the areas covered with fluorescent substance in the hands after washing indicated potentially remaining pathogens. The inability to perform scoring on photographs obtained from a hand scanner and the need for experienced observers constitute limitations of this study. However, the methodology used in this study allowed for a simpler and less costly form of evaluation technique to measure the effectiveness of HH.

Table 1 Comparison of total mean scores of hand hygiene beliefs, and skills in intervention (Glo germ) and control groups.

Intervention (Glo germ) Group (N = 63)

Control group (N = 63) Test results p value Effect size a(r)

95% confidence interval

Mean ± SD Median Mean ± SD Median Lower Upper

Hand Hygiene Beliefs Pretest HHBS 84.10 ± 4.86 84.00 (65–93) 85.12 ± 5.85 84.00 (42–99)

**Z = − 1.326 0.062 0.118 0.079 0.117

Posttest HHBS

88.37 ± 6.96 90.00 (71–100)

86.38 ± 8.30 87.00 (54–99)

**Z = − 2.406 0.016 0.214 0.091 0.291

Test results *Z = − 4.592 *Z = − 0.558 p value <0.001 0.557 Effect size b(r)

0.409 0.049

95% Confidence interval

Lower 0.199 0.008 Upper 0.450 0.250

Hand Washing Skill First HWS 11.75 ± 2.94 12.00 (7–17) 11.73 ± 3.22 12.00 (3–18) **Z = − 1.471 0.141 0.013 0.068 0.174 Final HWS 20.62 ± 4.07 20.00 (7–28) 12.57 ± 2.85 12.00 (7–18) **Z = − 9.040 <0.001 0.805 0.702 0.867 Test results *Z = − 6.854 *Z = − 1.763 p value <0.001 0.078 Effect size b(r)

0.863 0.222

95% Confidence interval

Lower 0.712 0.018 Upper 0.827 0.281

SD = Standart Deviation, HH = Hand hygiene;; HHBS = hand hygiene belief scale; *Wilcoxon Signed Rank Test, **Mann-Whitney U test.

a r (=Z/(√Nobs)). b r (=Z/(√Npairs)).

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5. Conclusion

The pre-test findings of this study showed that NSs generally had positive beliefs about the importance and necessity of HH. However, evaluating their handwashing skills revealed that NSs were not applying

this basic skill effectively. The post-test findings of the study showed that HH education which included visual feedback from the fluorescent compound glo germ was a useful strategy for improving some of the negative attitudes of NSs towards HH and improving effective hand- washing behavior.

Table 2 Distribution of mean scores in hand hygiene belief scale in intervention (Glo germ) and control groups.

Statements Intervention (Glo germ) group (N = 63) Control group (N = 63) 95% confidence interval

Pretest Mean ± SD

Posttest Mean ± SD

p value

Effect size a(r)

95% Confidence interval

Pretest Mean ± SD

Posttest Mean ± SD

Effect size a(r)

Lower Upper p value

Lower Upper

Hand hygiene is considered as an important part of the curriculum

4.46 ± 0.71

4.67 ± 0.47

0.212 0.157 0.009 0.320 4.51 ± 0.66

4.57 ± 0.61

0.067 0.230 0.105 0.196

The facilities in which I do clinical practicum emphasize the importance of hand hygiene.

3.94 ± 0.91

4.17 ± 0.66

0.010 0.326 0.003 0.279 3.81 ± 0.93

4.10 ± 0.94

0.331 0.148 0.99 0.303

The importance of hand hygiene is emphasized by my clinical supervisors

3.57 ± 1.10

3.70 ± 1.07

0.301 0.130 0.103 0.217 3.70 ± 1.01

3.79 ± 0.91

0.549 0.075 0.021 0.120

I have a duty to act as a role model for other healthcare workers

4.29 ± 0.68

4.33 ± 0.91

0.489 0.087 0.023 0.145 4.05 ± 0.86

4.49 ± 0.61

p < .001

0.484 0.153 0.397

When busy, it is more important to complete my task than to perform hand hygiene*

4.30 ± 0.77

1.97 ± 1.03

p <. 001

0.795 0.720 0.835 4.11 ± 0.77

2.00 ± 1.00

p < .001

0.796 0.691 0.814

Performing hand hygiene in the recommended situations can reduce patient mortality

4.29 ± 0.81

4.60 ± 0.66

0.017 0.302 0.057 0.338 4.44 ± 0.73

4.67 ± 0.47

0.032 0.270 0.030 0.324

Performing hand hygiene in recommended situations can reduce medical costs associated with hospital-acquired infections

4.54 ± 0.61

4.68 ± 0.71

0.060 0.237 0.048 0.251 4.49 ± 0.80

4.70 ± 0.46

0.041 0.257 0.078 0.302

I can’t always perform hand hygiene in recommended situations because my patient’s needs come first*

3.62 ± 1.02

1.90 ± 0.66

p <. 001

0.757 0.624 0.768 3.56 ± 1.01

2.51 ± 1.03

p < .001

0.499 0.338 0.554

Prevention of hospital-acquired infections is a valuable part of a healthcare worker’s role

4.73 ± 0.44

5.00 ± 00.0

p < .001

0.519 0.236 0.527 4.65 ± 0.60

4.68 ± 0.50

0.834 0.026 0.043 0.195

I follow the guidelines of senior healthcare workers when deciding whether or not to perform hand hygiene

3.41 ± 1.17

3.59 ± 1.24

0.189 0.165 0.085 0.228 3.65 ± 1.24

3.86 ± 1.21

0.255 0.143 0.076 0.240

An infectious disease in a healthcare setting may threat my life or career

4.60 ± 0.49

4.70 ± 0.46

0.648 0.057 0.065 0.265 4.52 ± 0.87

4.54 ± 0.73

0.124 0.193 0.143 0.167

I believe I have the power to change poor practices in the workplace

3.87 ± 0.83

4.54 ± 0.53

p < .001

0.570 0.315 0.531 3.73 ± 0.95

4.06 ± 0.78

0.008 0.331 0.041 0.318

Failure to perform hand hygiene in the recommended situations can be considered negligence

4.08 ± 0.92

4.54 ± 0.50

p < .001

0.487 0.162 0.413 3.95 ± 0.79

4.29 ± 0.72

0.006 0.348 0.077 0.347

Hand hygiene is a habit for me in my personal life

4.62 ± 0.52

4.70 ± 0.46

0.197 0.162 0.079 0.235 4.52 ± 0.66

4.60 ± 0.52

0.458 0.093 0.099 0.127

I am confident I can effectively apply my knowledge of hand hygiene to my clinical practice

4.41 ± 0.55

4.57 ± 0.49

0.025 0.281 0.097 0.290 4.37 ± 0.63

4.41 ± 0.61

0.577 0.070 0.082 0.102

I try to remember performing hand hygiene in recommended situations*

2.75 ± 1.16

2.25 ± 0.65

0.008 0.334 0.109 0.387 2.43 ± 0.97

3.52 ± 1.13

p < .001

0.522 0.344 0.553

I would feel uncomfortable reminding a health professional to wash his hands*

3.13 ± 1.14

2.35 ± 0.74

p < .001

0.487 0.248 0.483 2.87 ± 1.17

3.32 ± 1.22

0.067 0.280 0.035 0.321

Performing hand hygiene slows immunity against diseases*

3.79 ± 1.28

1.90 ± 0.73

p < .001

0.718 0.580 0.739 3.21 ± 1.24

2.94 ± 1.33

0.376 0.111 0.061 0.165

Dirty sinks can be a reason for not washing hands*

3.38 ± 1.17

2.41 ± 0.66

p < .001

0.541 0.116 0.394 3.32 ± 1.09

2.81 ± 1.16

0.052 0.245 0.068 0.357

Lack of soap can be a reason for not cleansing hands*

3.30 ± 1.21

2.63 ± 1.12

0.010 0.323 0.132 0.401 3.29 ± 1.06

2.89 ± 1.12

0.090 0.213 0.024 0.322

Performing hand hygiene after caring for a wound can protect from transmission of infectious diseases

4.59 ± 0.55

5.00 ± 00.0

p < .001

0.596 0.407 0.652 4.54 ± 0.80

4.57 ± 0.71

0.509 0.083 0.046 0.183

Cleansing hands after going to the toilet can reduce transmission of infectious disease

4.70 ± 0.49

4.98 ± 0.12

p < .001

0.483 0.217 0.488 4.62 ± 0.85

4.71 ± 0.49

0.537 0.077 0.103 0.227

*negative items HHBS = hand hygiene belief scale p: Wilcoxon Signed Rank Test. a r (=Z/(√Npairs)).

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5.1. Clinical implications

Attaching more importance to effective HH education within the scope of the core nursing curriculum, and the use of effective teaching methods to teach this basic skill is necessary. This is important because of the potential negative effects of a lack of skills on HH compliance during students’ clinical practice. Glo germ, a fluorescent compound, can provide an opportunity for students to better understand the results of their HH behaviors and their own competence through visual feed- back. However, it is recommended that give continuous feedback on the effectiveness of the HH behaviors that students exhibit in clinical learning environments. Nursing educators and curriculum developers will be able to benefit from the results of this study and use them to educate competent nurse candidates in the management of HAIs, to develop theoretical and clinical training programs that aim to improve NSs’ knowledge, attitudes and skills with regard to HH and to improve specific aspects of the existing curricula. Future trials should be con- ducted to inform decisions on the routine use of a Glo germ in HH education.

Funding sources

This study was funded by the Scientific and Technological Research Council of Turkey (TÜBİTAK) as part of the 3001- Starting R&D Projects Funding Program Project with number 118S625.

Declaration of competing interest

The authors declare no conflict of interest.

Acknowledgments

We thank all the nursing students who participated to the study.

Ethical considerations

Ethical approval for the study was obtained from the Clinical Research Ethics Committee of the Afyon Kocatepe University (Date/ No:2018-69).

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Table 3 Distribution of mean scores of nursing students’ hand hygiene skills.

Intervention (Glo germ) group (N = 63) Control group (N = 63)

First hand washing Final hand washing Within group First hand washing Final hand washing Within group

Areas of evaluated hand

Mean ± SD

Mean ± SD

Test value and significance

Effect size a(r)

95% confidence interval

Mean ± SD

Mean ± SD

Test value and significance

Effect size a(r)

95% confidence interval

Lower Upper Lower Upper

Finger tips 2.05 ± 0.65

3.03 ± 0.62

Z = − 5.893 p < .001

0.742 0.519 0.618 1.79 ± 0.51

2.06 ± 0.64

Z = − 2.573 p = .010

0.324 0.082 0.357

Nails 1.57 ± 0.58

2.87 ± 0.75

Z = − 6.441 p < .001

0.811 0.615 0.756 1.65 ± 0.62

1.71 ± 0.63

Z = − 0.624 p = .532

0.078 0.119 0.210

Palms 2.19 ± 0.66

3.03 ± 0.64

Z = − 5.572 p < .001

0.702 0.444 0.621 2.22 ± 0.70

2.48 ± 0.71

Z = − 2.258 p = .024

0.284 0.032 0.317

Dorsum of hand 1.43 ± 0.58

2.75 ± 0.82

Z = − 6.708 p < .001

0.845 0.598 0.742 1.52 ± 0.61

1.75 ± 0.58

Z = − 2.271 p = .024

0.284 0.040 0.325

Between fingers 1.79 ± 0.51

3.05 ± 0.79

Z = − 6.381 p < .001

0.803 0.631 0.771 1.70 ± 0.66

1.86 ± 0.50

Z = − 1.617 p = .106

0.203 0.022 0.282

Thumb 1.38 ± 0.49

2.92 ± 0.72

Z = − 6.804 p < .001

0.857 0.711 0.829 1.37 ± 0.57

1.49 ± 0.53

Z = − 1.706 p = .088

0.214 0.018 0.283

Wrist 1.33 ± 0.50

2.97 ± 0.82

Z = − 6.804 p < .001

0.857 0.820 0.699 1.33 ± 0.47

1.46 ± 0.56

Z = − 1.569 p = .117

0.197 0.033 0.272

p: Wilcoxon Signed Rank Test a r (=Z/(√Npairs)).

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