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Effectiveness of Hygienic Hand Washing Training on Hand Washing Practices and Knowledge: A Nonrandomized Quasi-Experimental Design Mete Kagan Karaoglu, BSc, RN, MSc; and Semiha Akin, BSc, RN, MSc, PhD

Hygiene is considered as an integral part of hospital infection control. Hygiene refers to hand washing using antiseptic hand wash, antiseptic hand rub, or surgical hand antiseptics to reduce the spread of micro- organisms and infection. Hygiene includes the practices and precautions to prevent the spread of infectious diseases and microorganisms from one environment to another (World Health Organization [WHO], 2009). Although the hospital-acquired infection rate for inpatients is 5% to

10%, that rate exceeds 20% to 25% in intensive care units (Yurttaş, Kaya, & Engin, 2017). Compliance with hygiene practices and infection control precautions such as hand hy- giene reduces the incidence of hospital-acquired infections and financial burdens and prevents long-term disability (Koşucu, Göktaş, & Yıldız, 2015; WHO, 2009).

Guidelines published by the Centers for Disease Con- trol and Prevention (CDC) in 2002 and the WHO in 2009 emphasized that multidisciplinary hand hygiene promotion programs and alcohol-based hand rubs have been reported to improve hand hygiene practices of health care staff (CDC, 2002; WHO, 2009). Hospital workers’ hands are one of the most important sources of infections among patients (Yurttaş, Kaya, & Engin, 2017). With simple hygienic applications such as washing the hands with soap and water or alcohol-based hand rubs, many in- fectious diseases could be prevented (Deveci, Açık, Ercan, Ferdane, & Oğuzöncül, 2010). Although the importance of washing hands for infection prevention is well known, compliance with hand hygiene practices among health care staff continues to be a frequently encountered prob- lem (Sadeghi-Moghaddam, Arjmandnia, Shokrollahi, & Aghaali, 2015; WHO, 2009).

The WHO (2009) states that the assessment of hand hygiene indications and actions should be monitored to

Nurses undertake important responsibilities in patient care and the prevention of hospital-acquired infections. However, adherence to hand hygiene practices among nurses has been reported to be low. This study aims to evaluate the effectiveness of hygienic hand washing training on hand washing practices and knowledge. The study design was a nonrandomized, quasi-experimental study, with pretest–posttest for one group. Pre- and postobservations were also conducted using an observa- tion form on any 5 workdays to evaluate the effective- ness of hygienic hand washing training on hand washing practices. The study was conducted with 63 nurses work- ing at a hospital in Istanbul. Hand Hygiene Knowledge Form scores after hygienic hand washing training were higher than the pretraining scores. The number of the nurses’ hand hygiene actions after hand hygiene train- ing increased significantly compared with that before training. The results indicate that training in proper hand washing techniques and hygienic hand washing practices positively affects the knowledge level of nurses and their hand washing behavior. J Contin Educ Nurs. 2018;49(8):360-371.

abstract

Mr. Karaoglu is Faculty, Hematology/Oncology Ward, Florence Night- ingale Hospital, and Dr. Akin is Associate Professor, Faculty of Nursing, University of Health Sciences, Istanbul, Turkey.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Semiha Akin, BSc, RN, MSc, PhD, Associ- ate Professor, Faculty of Nursing, University of Health Sciences, Mekteb-i Tıbbiye-i Sahane (Haydarpasa) Kulliyesi Selimiye Mahallesi, Tibbiye Cad. No:38, 34668 Uskudar, Istanbul, Turkey; e-mail: [email protected].

Received: August 1, 2017; Accepted: April 12, 2018 doi:10.3928/00220124-20180718-07

361The Journal of Continuing Education in Nursing · Vol 49, No 8, 2018

improve approaches for the prevention of health care- associated infections and the transmission of microorgan- isms. Direct observation is still considered the gold stan- dard for monitoring compliance with hand hygiene and is a widely used assessment technique, providing more accu- rate and reliable data (CDC, 2002; WHO, 2009). Hand hygiene actions that health care staff should follow include washing hands (a) before patient contact, (b) before asep- tic tasks, (c) after body fluid exposure risk, (d) after patient contact, and (e) after contact with patient surroundings. Observational studies reported poor adherence to hand hygiene procedures among health care staff (CDC, 2002).

The term hand hygiene refers to hand washing using soap and water, antiseptic hand wash, antiseptic hand rub, or surgical hand antiseptics. Alcohol-based hand rubs in- tended for use in hospitals (e.g., gels, foams) are available in the units. Both hand washing and alcohol-based hand rubbing are considered hand hygiene practices. Nurses are encouraged to use alcohol-based hand antiseptics and to wash their hands with soap and water when their hands are visibly dirty, before exposure to patients with infec- tious diseases, before eating, and after using the restroom.

Hand hygiene practices are influenced by personal and professional characteristics of the health care staff, type of hospital unit, workload, and perceptional, environmental, and organizational factors (Erkan, 2010; Joint Commis- sion, 2009; WHO, 2009). Education, motivation, regular direct or indirect monitoring and feedback, and behav- ioral and administrative measures may help address poor hand washing practices (WHO, 2009).

Multidisciplinary behavioral approaches and train- ing have been reported to improve hand hygiene com- pliance among nurses and other health care profession- als (Freeman et al., 2016; Rn, Jones, Martello, Biron, & Lavoie-Tremblay, 2017; Sadeghi-Moghaddam et al., 2015; Santosaningsih et al., 2017; von Lengerke et al., 2017). A randomized controlled trial showed that edu- cational interventions improved both compliance rate for proper hand hygiene practices and knowledge of effective hand hygiene practices (Santosaningsih et al., 2017). Sim- ilarly, a systematic review revealed that educational inter- ventions improved proper hand hygiene practices (Rn et al., 2017). Besides having positive effects on hand hygiene compliance rates, educational interventions on proper hand hygiene practices have also been shown to decrease (Sadeghi-Moghaddam et al., 2015). These findings sug- gest the importance of further implementing educational strategies to improve hand hygiene practices.

Nurses working in specialized units such as oncology wards, intensive care units, and transplant units must have sufficient knowledge about infection control and must adopt proper hand hygiene practices to prevent the

spread of hospital-acquired infections among patients. For hospital-acquired infections to be successfully controlled, nurses should be sensitive about hand hygiene and be sup- ported with regard to washing their hands. An assessment of hand hygiene practices among nurses and the need for improving their compliance with proper hand hygiene practices will help develop multidisciplinary (administra- tive staff, infection control nurse and physicians, pharma- cists) hand hygiene promotion strategies.

STUDY AIM This study was conducted to evaluate the extent to

which nurses’ knowledge levels and hand washing prac- tices are affected by training on proper hand washing tech- niques and hygienic hand washing practices. This was a nonrandomized quasi-experimental study, in which the pretest–posttest order for a single group was used. The study hypotheses were: l Hygienic hand washing training increases the level of

nurses’ knowledge of hand hygiene and proper hand washing techniques.

l Hygienic hand washing training positively affects nurs- es’ compliance with hand hygiene and practices regard- ing proper hand washing techniques.

METHOD Study Location

The study was conducted at a hospital’s hematology and oncology wards, chemotherapy unit, surgical inten- sive care unit, and transplant units.

Study Population and Sample The study population consisted of 88 nurses working

in the hospital’s hematology wards, oncology wards, che- motherapy unit, surgical intensive care unit, and trans- plant units. Nurses who (a) volunteered to participate in the study and (b) took primary responsibility for patient care were included in the sample (convenience sampling method). To determine the sample size, a power analysis was performed using the G*Power (v3.17) program. Ac- cording to Cohen’s effect size coefficients, and according to calculations made with the assumption that evaluations to be made between two dependent groups should have a large effect size (d = 0.44), the sample size of nurses was found to be at least 48. However, possible losses during the study were taken into consideration, and all 63 nurses were included in the study.

Ethical Considerations Ethical committee permission was obtained to conduct

the research. Institutional permission was granted by the hospital administration. Data were collected using three

data collection tools. The permission for using Hand Washing Observation Tool was obtained from the tool’s

developer. The researchers prepared the Nurse Knowledge Form and the Hand Hygiene Knowledge Form.

The nurses were told that the study was being performed to assess their knowledge about hand hygiene. They were asked not to include any information that revealed their identity. Their verbal and written informed consent was obtained. Those who gave informed consent were includ- ed in the sample, and anonymity was preserved.

Data Collection Tools Data were collected using the data collection tools list-

ed below through questionnaires and direct observation. Nurse Knowledge Form. This form included questions

regarding the nurses’ sociodemographic characteristics and the characteristics of the units where they worked.

Hand Washing Observation Tool. Data were collected using the Hand Washing Observation Tool. This obser- vation tool was prepared by Çağlar in 2007 based on principles defined by the CDC’s 2002 guidelines for hand hygiene practices. This tool has been reviewed by experts in infection control. The Hand Washing Obser- vation Tool was tested in a pilot study in the research (Çağlar, 2007).

The Hand Washing Observation Tool assessed nurses’ hand washing practice at the start (entry into the unit) of the shift. The tool also assessed nurses’ hand washing opportuni- ties and hand hygiene compliance during the shift. Those who washed their hands in line with hand washing indications were assessed with respect to proper hand hygiene techniques, the product used for hand washing, and the amount of time spent rubbing the hands together vigorously (Çağlar, 2007).

The Hand Washing Observation Tool is based on prin- ciples defined by CDC’s 2002 guidelines for hand hygiene practices (Çağlar, 2007). The hand washing observation tool was created based on terms found in the CDC’s 2002 guidelines, such as “improper hand washing technique,” “proper hand washing technique,” and “partially prop- er” hand washing techniques. The terms of “improper,” “proper,” and “partially proper” techniques have been de- fined based on definitions in the Guideline for Hand Hy- giene in Health-Care Settings (Çağlar, 2007).

Washing hands for at least 2 minutes and following the CDC’s (2002) recommendations for hand-washing tech- niques were the criteria used to define the proper hand washing technique. Hand washing for less than 2 minutes, while following the other recommendations of the CDC’s 2002 guidelines for hand washing techniques, was the criteria used to define the partially proper hand washing technique. Those who did not follow the CDC recom- mendations for hand washing technique regardless of the time spent hand washing were categorized as those who practiced an improper hand washing technique.

Figure. Study design and data collection.

363The Journal of Continuing Education in Nursing · Vol 49, No 8, 2018

Hand Hygiene Knowledge Form. The Hand Hygiene Knowledge Form included multiple choice questions about the nurses’ knowledge levels regarding hand hy- giene. The Nurse Knowledge Form was prepared by the researchers (the authors) of the current study. The first sec- tion consists of 15 questions for a minimum of 0 and a maximum of 15 points. The second section consists of 13 questions. Items are answered as either correct, incorrect, or I don’t know. Each correct answer is scored as 1 point and each incorrect answer or I don’t know answer is scored as 0 points, for a minimum of 0 and a maximum of 13 points.

Procedure Data were collected between March 3, 2017, and April 7,

2017. The phases of data collection are shown in the Figure. Pilot Study. For our study, the infection control nurse

of the hospital trained one of the researchers (M.K.K.) on hand-washing techniques using the Hand Washing Observation Tool. Following this training, the researcher and the infection control nurses independently conducted pilot observations. The infection control nurse and the other researcher compared the results of both observa- tions. There were no significant differences between the researcher’s observations and the infection control nurse’s observations. Before the current study, a pilot investiga- tion of five nurses was conducted to assess the utility of the Hand Washing Observation Tool. This investigation revealed that the tool is easy to use and applicable.

Observation of Hand Washing Practices Before Training (First Observation). Observation was performed using an observation form on any five workdays between the hours of 8:00 a.m. and 4:00 p.m. when patient care efforts were most active. Each nurse was watched for 4 hours without knowing they were being observed (a total of 252 hours for the first observation). There was a sufficient number of sinks in each unit that were easily accessible for nurses to use during clinical shifts. The nurses were also followed into restrooms to observe their hand washing techniques.

Evaluation of Knowledge Levels Before the Hygienic Hand Washing Training (Pretest). The knowledge levels of the nurses regarding hygienic hand washing were evaluated using the Hand Hygiene Knowledge Form.

Hygienic Hand Washing Training. The researchers gave the hygienic hand washing training. This training was done for approximately 20 minutes for 12 times in groups of five to seven nurses.

Observation of Hand Washing Practices After the Train- ing (Second Observation). After the hygienic hand washing training, for a minimum of 2 weeks and a maximum of 4 weeks, the nurses’ hand washing behavior was observed for the second time using the Hand Washing Observation Tool. Each nurse was observed for 4 hours.

Evaluation of Knowledge After Hygienic Hand Washing Training (Posttest). After the hygienic hand washing train- ing, for a minimum of 2 and a maximum of 4 weeks, the posttest was applied (Hand Hygiene Knowledge Form).

Data Evaluation and Statistical Analysis For statistical analyses, the Number Cruncher Statisti-

cal System program was used. During the evaluation of the

TABLE 1

PERSONAL CHARACTERISTICS OF NURSES (N = 63)

Variable Min-Max (Median) Mean 6 SD

Age (years) 19 to 44 (24) 24.73 6 4.84

Length of employment as nurse (months)

1 to 312 (34) 42.59 6 50.83

Length of employment at the current hospital ward (months)

1 to 228 (18) 28.81 6 33.71

Number of patients given daily care

2 to 30 (7) 8.05 6 5.50

Variable n %

Gender

Female 56 88.9

Male 7 11.1

Education

Vocational nursing school graduates

12 19.1

Associate’s degree 5 7.9

Bachelor’s degree 41 65.1

Master’s degree 5 7.9

Marital status

Single 56 88.9

Married 7 11.1

Hospital unit or ward

Oncology wards 7 11.1

Hematology ward 10 15.9

Intensive care unit 7 11.1

Hematopoietic stem cell transplantation unit

15 23.8

Liver transplantation unit 9 14.3

Chemotherapy unit 7 11.1

Renal transplantation unit 8 12.7

Obtaining education about infection control

No 14 22.2

Yes 49 77.8

study data, in addition to using descriptive statistical meth- ods (mean values, standard deviation, medians, frequencies, percentages, minimums, and maximums), the compliance of quantitative data to a normal distribution was tested us- ing the Shapiro–Wilk test and graphical examinations. The Mann–Whitney U test was used to compare quantitative data that did not exhibit normal distribution between two groups.

The Kruskal–Wallis test was used to compare quantita- tive data that did not show normal distribution between more than two groups, and if there were differences, the Dunn–Bonferroni test was used for the two-way evalua- tion. The Wilcoxon signed-rank test was used to compare quantitative data that did not exhibit normal distribution within groups. The marginal homogeneity test was used to compare qualitative data within groups. The Spear- man correlation analysis was used to evaluate relationships between quantitative variables. Statistical significance (p) was .05.

RESULTS Nurses’ Personal Characteristics

During the data collection period, 63 of 88 nurses met the inclusion criteria. Twenty-five nurses were not included because they were either too busy to complete the knowl- edge form, could not be reached, or were not accessible (e.g., on sick or annual leave). Among the participants, 65.1% had a bachelor’s degree in nursing, and the mean age was 24.73 6 4.84. Nearly one-quarter of the nurses (23.8%) worked at the hematopoietic stem cell transplanta- tion unit (Table 1).

Nurses’ Knowledge Regarding Hand Hygiene The Hand Hygiene Knowledge Form’s correct answer

rates increased significantly after the hand washing train- ing. Across all the nurses, the changes observed in the Hand Hygiene Knowledge Form total scores after the training compared with before were statistically signifi- cant (p , .001) (Table 2). The knowledge scores after the training were found to be significantly higher than those before hand washing training (Table 3).

The current study did not find any statistically signifi- cant relationship between the Hand Hygiene Knowledge Form total scores at the pretraining and posttraining pe- riod and length of time working as a nurse (p . .05). No statistically significant relationship was found between the Hand Hygiene Knowledge Form total scores obtained at the pretraining and posttraining period with regard to the nurses’ length of employment on the current hospital ward (p . .05).

A statistically significant increase in posttraining scores was detected between the Hand Hygiene Knowledge Form scores with regard to variables such as marital status, gender, clinical unit where the nurses worked, and status of receiving infection control training (p , .05) (Table 4).

Nurses’ Hand Washing Rates Before and After Training

The rate of observed hand washing episodes increased after hand washing training; however, hand hygiene compliance rates were still low both before and after hand washing training (Table 2). Pretraining hand hy- giene rates were between 0% and 2.3%. Hand hygiene

TABLE 2

COMPARISON OF HAND HYGIENE KNOWLEDGE FORM TOTAL SCORES BEFORE AND AFTER HYGIENIC HAND WASHING TRAINING (N = 63)

Hand Hygiene Knowledge Form Total Scores

Knowledge Median (Q1, Q3) Mean 6 SD pa

Before hygienic hand washing training 15 (12, 18) 14.70 6 4.14 , .001**

After hygienic hand washing training 27 (25, 28) 25.79 6 2.64

Difference (after training versus before training) 11 (8, 14) 11.10 6 5.02

Hand Washing Rates Using Proper Technique

Hand Washing Rates Median (Q1, Q3) Mean 6 SD pa

Before hygienic hand washing training 0 (0, 0) 1.08 6 3.46 , .001**

After hygienic hand washing training 10 (0, 20) 13.33 6 11.94

Difference (after training versus before training) 10 (0, 20) 12.25 6 12.59

Note. Q1 = quartile 1; Q3 = quartile 3. a Wilcoxon signed-rank test. **p , .01.

365The Journal of Continuing Education in Nursing · Vol 49, No 8, 2018

TABLE 3

CORRECT ANSWERS TO THE HAND HYGIENE KNOWLEDGE FORM BEFORE AND AFTER HYGIENIC HAND WASHING TRAINING (N = 63)

Hygienic Hand Washing Training

First Part of the Questionnaire Before, n (%) After, n (%)

1. What is the purpose of hygienic hand washing? 42 (66.7) 54 (85.7)

2. Why is it important to apply hand hygiene in the best manner? 40 (63.5) 58 (92.1)

3. Your hand has been contaminated with blood or bodily fluids. In this case, what is the best method to remove pathogen bacteria from your hands?

26 (41.3) 62 (98.4)

4. In which of the cases below, the hands do not need to be washed? 2 (3.2) 59 (93.7)

5. Read the situations listed below. In which of those is a hand wash not completely necessary? 30 (47.6) 58 (92.1)

6. Which of the below is the most effective hand washing method? 13 (20.6) 59 (93.7)

7. How long should a hygienic hand wash take? 32 (50.8) 62 (98.4)

8. In the hand washing process using an antiseptic solution, how many seconds should the hands be rubbed?

18 (28.6) 61 (96.8)

9. Which is the most appropriate way to dry hands? 36 (57.1) 60 (95.2)

10. Which of the items below is more resistant to antiseptic solutions? 25 (39.7) 59 (93.7)

11. How long should the natural nails be of health workers responsible for the care of high-risk patients?

26 (41.3) 61 (96.8)

12. Which one is not a factor that may disrupt hand hygiene? 44 (69.8) 61 (96.8)

13. When there are suspected spore bacteria, which is the most effective hand washing method? 21 (33.3) 59 (93.7)

14. Where are the locations often overlooked during washing hands? 4 (6.3) 59 (93.7)

15. What should be the temperature of water suggested for effective and appropriate hand washing?

50 (79.4) 61 (96.8)

Hygienic Hand Washing Training

Second Part of the Questionnaire Before, n (%) After, n (%)

1. Hands should be washed before contact with patients. 56 (88.9) 60 (95.2)

2. After the gloves are removed, the hands do not need to be decontaminated. 41 (65.1) 53 (84.1)

3. Hands should be washed before aseptic processes. 57 (90.5) 62 (98.4)

4. Hands should be washed after contamination with bodily fluids. 58 (92.1) 62 (98.4)

5. Hands should be washed after contact with patients (measuring pulse or blood pressure, lifting the patient up, etc.).

55 (87.3) 61 (96.8)

6. Hands should be washed after contact with the patient environment. 52 (82.5) 61 (96.8)

7. During patient care, while going from clean body parts to contaminated body parts, hands should be decontaminated.

20 (31.7) 45 (71.4)

8. Immediately after contact with inanimate matter (including medical tools), hands should be decontaminated.

38 (60.3) 56 (88.9)

9. If the hands are not visibly contaminated, it is suggested that the hands should be rubbed with an alcohol-based solution for routine decontamination.

29 (46) 52 (82.5)

10. Alcohol-based antiseptics are not effective against most hospital-based microorganisms. 23 (36.5) 50 (79.4)

11. Wet wipes with antimicrobials can be used instead of the process of washing hands with non- antimicrobial soap and water.

33 (52.4) 59 (93.7)

12. If there is suspected or certain contact with Bacillus anthracis, hands should be washed with soap and water.

46 (73) 59 (93.7)

13. Alcohol, chlorhexidine, iodophors, and other antiseptic agents are very effective against spores. 9 (14.3) 52 (82.5)

compliance rates posttraining varied between 0% and 42% (Table 5).

Hand washing rates were examined before and after training. After the training, compared with before, a widely varying amount of increase between 0% and 50% was seen in hand washing rates. This result showed that, despite hand hygiene training, hand washing rates were still low and there was a need for improvement (Table 5).

The distributions regarding hand washing techniques and hand washing according to hand washing indications are shown in Table 6. The increase was seen in proper hand washing rates across the nurses’ posttraining and was statistically significant (p , .001).

After the training, situations that required hand washing were fulfilled at 25.6% after glove removal, 23% after contact or care with patients, 22.9% be- fore contact or care with patients, 7.3% after contact

TABLE 4

COMPARISON OF HAND HYGIENE KNOWLEDGE SCORES ACCORDING TO PERSONAL CHARACTERISTICS (N = 63)

Hand Hygiene Knowledge Form Total Scores

Before Hygienic Hand Washing Training, Median

(Q1, Q3)

After Hygienic Hand Washing Training, Median

(Q1, Q3)

Difference (After Training Versus Before Training),

Median (Q1, Q3) pa

Gender

Female 15.5 (12, 18.5) 27 (24, 28) 11 (7.5, 14) , .001**

Male 13 (9, 17) 27 (26, 28) 14 (10, 17) .018*

pb .25 .42 .11

Education

Vocational nursing school graduates

13 (11.5, 18) 26 (23.5, 28) 11.5 (9, 12) .002**

Associate’s degree 13 (8, 18) 25 (25, 27) 14 (3, 17) .07

Bachelor’s degree 15 (12, 17) 27 (26, 28) 11 (8, 15) , .001**

Master's degree 19 (18, 19) 27 (26, 27) 8 (6, 9) .042*

pc .12 .52 .29

Hospital unit/ward

Oncology wards 13 (11, 15) 27 (26, 28) 14 (11, 17) .018*

Hematology ward 15.5 (11, 17) 27 (25, 28) 12.5 (10, 17) .005**

Intensive care unit 18 (12, 20) 27 (26, 27) 8 (6, 15) .018*

Hematopoietic stem cell transplantation unit

14 (12, 19) 26 (23, 27) 10 (5, 13) .001**

Liver transplantation unit 17 (14, 19) 24 (22, 25) 8 (6, 10) .008*

Chemotherapy unit 12 (10, 16) 27 (27, 28) 14 (12, 18) .018*

Renal transplantation unit 17 (14.5, 17.5) 27 (26.5, 28) 10 (9, 12.5) .011*

pc .24 .018* .014*

History of obtaining education about infection control

No 14 (10, 17) 27.5 (26, 28) 12 (10, 15) .001**

Yes 16 (12, 18) 27 (25, 27) 11 (7, 14) , .001**

pb .15 .12 .16

Note. Q1 = quartile 1; Q2 = quartile 2. a Wilcoxon signed-rank test. b Mann-Whitney U test. c Kruskal-Wallis test. *p , .05. **p , .01.

367The Journal of Continuing Education in Nursing · Vol 49, No 8, 2018

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with lacerations, and 6.8% before contact with lac- erations.

After the hand washing training, water and soap was found to be used in 48.8% of hand washing processes,

TABLE 6

OBSERVED HAND WASHING CASES BEFORE AND AFTER HYGIENIC HAND WASHING TRAINING ACCORDING TO UNIT OR SERVICE AND HAND WASHING INDICATIONS (N = 63)

Hygienic Hand Washing Traininga

Before (Observation One = 703) After (Observation Two = 687)

Unit/ward

Oncology wards 88 (12.5%) 73 (10.6%)

Hematology ward 150 (21.3%) 115 (16.7%)

Intensive care unit 60 (8.5%) 75 (10.9%)

Hematopoietic stem cell transplantation unit 152 (21.6%) 164 (23.9%)

Liver transplantation unit 85 (12.1%) 103 (15%)

Chemotherapy unit 87 (12.4%) 72 (10.5%)

Renal transplantation unit 81 (11.5%) 85 (12.4%)

Hand washing indications

Before invasive operations 73 (10.4%) 36 (5.2%)

After invasive operations 71 (10.1%) 31 (4.5%)

Before contact with laceration 27 (3.8%) 47 (6.8%)

After contact with laceration 30 (4.3%) 50 (7.3%)

After the hands are contaminated with mucous membranes, blood or bodily fluids, secretions, or feces

4 (0.6%) 7 (1%)

After contact with inanimate objects contaminated with bodily fluids (bed sheets, laryngoscope, catheters)

32 (4.6%) 12 (1.7%)

Before contact with patient/care 171 (24.3%) 157 (22.9%)

After contact with patient/care 171 (24.3%) 158 (23%)

After unit-related applications 19 (2.7%) 13 (1.9%)

After removing gloves 105 (14.9%) 176 (25.6%)

Hand washing

No hand washing 427 (60.7%) 345 (50.2%)

Hand washing 276 (39.3%) 342 (49.8%)

Hand washing agent

Water and soup 151 (54.7%) 167 (48.8%)

Alcohol disinfectant 125 (45.3%) 175 (51.2%)

Hand washing technique

Improper technique 177 (64.1%) 105 (30.7%)

Proper technique 6 (2.2%) 89 (26%)

Partially proper technique 93 (33.7%) 148 (43.3%)

Length of hand washing

< 5 seconds 58 (21%) 86 (25.1%)

5 to 15 seconds 202 (73.2%) 147 (43%)

> 15 seconds 16 (5.8%) 109 (31.9%) a Percentages may not sum 100 due to rounding.

369The Journal of Continuing Education in Nursing · Vol 49, No 8, 2018

whereas disinfectant with alcohol was found to be used in 51.2%. The nurses were observed using the proper washing technique in only 26% of hand washing occa- sions.

DISCUSSION Knowledge Levels Regarding Hand Hygiene

The results of the current study showed that the train- ing was effective for improving the nurses’ knowledge of hand hygiene. This finding confirms the first hypothesis of the study. This result is meaningful because it shows the effectiveness of the training provided.

The nurses had less knowledge about hand washing indications, the least washed areas of the hands, and the antiseptic agents effective against spore-forming organisms. The nurses’ knowledge increased considerably following hand hygiene training. Similarly, their knowledge of anti- septic-resistant microorganisms also greatly improved. Al- though the percentage of correct answers after hand hygiene training was mostly above 90%, the results revealed that more frequent training is needed to improve the level of knowledge about the best way to remove microorganisms, the proper type of hand washing methods, and the factors interfering with hand hygiene. Çağlar (2007) observed the hand washing behaviors of health care workers working in the newborn unit. Most of the sample (77.78%) knew the correct location of microorganisms on their hands (deep lines in the palm and between fingers, fingertips, and nails) (Çağlar, 2007). The results showed that periodic training about hygiene and infection control measures may consid- erably improve knowledge and awareness.

The morbidity of infectious diseases is a major problem in specialized units such as transplantation, hematology, and oncology. Hygiene and infection control measures practiced in hospital settings may lead to lower hospi- talization rates and fewer quality-of-life disruptions. The comparison showed statistical significance between hand hygiene knowledge scores with respect to hospital units. A study by Demir et al. (2013) found no differences be- tween hospital units regarding the rate of correct answers given to questions on hand hygiene.

Nurses’ Hand Washing Rates Before and After Training

The posttraining compliance rates increased compared with pretraining compliance, although in general, the nurses’ compliance with hand hygiene was still poor. The current study also calculated the number of hand washing actions. The number of the nurses’ hand washing actions af- ter hand hygiene training increased significantly compared with that before training. Similarly, another study (Erkan, 2010) found that the number of nurses’ hand washing ac-

tions during a shift increased after training compared with that before training. After hygienic hand washing training, the hand hygiene compliance rates increased significantly. This finding confirmed the second hypothesis.

Studies show that nurses were the most compliant with hand hygiene practices among many health care workers. However, adherence to hand hygiene practices among nurses was reported as low (Al-Wazzan, Salmeen, Al-Amiri, Abul, Bouhaimed, & Al-Taiar, 2011; Çağlar, Yıldız, & Savaşer, 2010; Jansson, Syrjälä, Ohtonen, Mer- iläinen, Kyngäs, & Ala-Kokko, 2016; Karaarslan et al., 2014; Lee et al., 2014; Santosaningsih et al., 2017; Sastry, R, & Bhat, 2017; Seyed Nematian, Palenik, Mirmasoudi, Hatam, & Askarian, 2017). For instance, a study re- ported that a hygiene promotion program improved the hand hygiene practices, perceptions, and attitudes toward hand hygiene (Al-Wazzan et al., 2011; Lee et al., 2014). The hand hygiene compliance rate of health care workers (i.e., nurses and physicians) was reported to be 58.14% (Çağlar, 2007). Similar to the current study, a random- ized controlled study found that nurses’ adherence to hand hygiene practices increased from 40.8% to 50.8% following simulation education (Jansson et al., 2016). Similarly, a randomized control study conducted among health care workers revealed that hand compliance rates and knowledge of hand hygiene improved significantly (Santosaningsih et al., 2017). Health care workers’ overall compliance with hand hygiene in neonatal or pediatric in- tensive care units was 37% (Karaarslan et al., 2014). Hand hygiene compliance among nurses improved significantly from 52.3% to 91.2% following a hand hygiene promo- tion program (Lee et al., 2014). Complete hand hygiene adherence rates and partial adherence and nonadherence rates were 45.5%, 21.17%, and 33.3%, respectively (Sas- try, R, & Bhat, 2017). Overall, hand hygiene compliance was low, at 39.6% (Seyed Nematian et al., 2017).

An observational study revealed that the compliance rate for practicing proper hand hygiene among neona- tal and pediatric intensive care nurses was poor (41.4%) (Karaaslan et al., 2014) and this finding suggests develop- ing interventions for better hand hygiene practice. Simi- lar to the current study, an interventional study helped improve proper hand hygiene rates in health care provid- ers working at the neonatal intensive care unit (Sadeghi- Moghaddam et al., 2015). The hand hygiene adherence rates of trained nurses were higher than those of untrained nurses before contact with patients (Teker et al., 2015). The compliance rate of Turkish nurses working at a uni- versity hospital to the five hand hygiene indications was 78% (Şen, Sönmezoğlu, Akbal, Uğur, & Afacan, 2013). The compliance rate of nurses with hand hygiene was 69% (Koşucu et al., 2015).

All these results indicate that there is still much to do to improve nurses’ compliance with hand hygiene. Con- sistent with other research, the current study results con- firmed that education and hygiene promotion programs both influence nurses’ knowledge about compliance with hand hygiene and improve hand hygiene adherence. Fre- quent education programs, role models, and monitoring are needed to improve adherence to hand hygiene practices. All the study findings support that education for improving hand hygiene adherence rates is crucial. Assessment of hand washing opportunities and observing hand washing actions, conducting surveys, and measuring hand washing product use will provide data for overcoming challenges at the clini- cal area and developing effective strategies for improving hand washing adherence (Joint Commission, 2009).

Before hygienic hand washing training, the hands were most often washed before contact with patients, after con- tact with patients, and after glove removal. After hygienic hand washing training, the hands were washed most often after glove removal, after contact with patients, and before contact with patients. Guanche Garcell, Villanueva Arias, Ramírez Miranda, Rubiera Jimenez, and Alfonso Serrano (2017) found that the health care staff were most compli- ant with hand hygiene practices after exposure to blood or body fluids and after patient contact and were least com- pliant with hand hygiene practices before patient contact and before aseptic procedures. Another study conducted in a Turkish hospital reported that nurses washed their hands the most after touching a patient, after touching pa- tient surroundings, before touching the patient, and after exposure to blood or body fluids, respectively (Karaaslan et al., 2014). These results show that nurses’ attitudes and practices about hand washing indications need to be sup- ported with regular educational programs.

Of 687 hand washing indications, nurses washed their hands 342 times. This finding shows that compliance with hand washing was 49.8%, compared with 39.3% pretraining (of 703 hand washing indications). The rate of proper washing techniques for hand hygiene tested the in posttraining observation increased (26%) compared with that in pretraining observation (2.2%), although the per- centage was still low. As reported by Erkan (2010), the rate of nurses using proper hand washing techniques was 49.5% before training and 83% after training.

A small group of nurses (13.33%) was observed to have washed their hands using the proper technique (Çağlar, 2007). Demir et al. (2013) found that the hand wash- ing rate was below 50%. Hand hygiene compliance rate was observed to be suboptimal among emergency depart- ment and intensive care nurses (Stahmeyer, Lutze, von Lengerke, Chaberny, & Krauth, 2017). However, when compared with other health professionals, the nurses had

higher compliance rates with hand hygiene. A nurse’s workload was identified as a major factor associated with poor hand hygiene (Scheithauer, Batzer, Dangel, Passweg, & Widmer, 2017). Some obstacles to hygiene barriers, such as using protective equipment or carrying something in the hands, have been found to influence compliance with proper hand hygiene practices (Kurtz, 2017). There are many factors that may negatively influence the rate of using proper hand washing, such as occupational experi- ence, a high number of patients per nurse, and a lack of sufficient number of nurses.

Similar to the current study, some studies showed that soap and water were commonly used instead of alcohol- based hand disinfectants. For example, one study found that soap and water was more commonly preferred for a hand hygiene product than alcohol-based hand disinfec- tants by neonatal and pediatric intensive care nurses (Kara- aslan et al., 2014). The rate of using alcohol-based hand dis- infectants for proper hand hygiene practices among nurses is reported to be low (Seyed Nematian et al., 2017).

LIMITATIONS Knowledge about hand hygiene and nurses’ compliance

with hand hygiene practices were assessed only once fol- lowing the second to fourth weeks of hand hygiene train- ing. This study does not provide any data about long-term changes in nurses’ knowledge and compliance with hand hygiene practices following hand washing posttraining. The other limitation is the hand hygiene compliance and hand washing behaviors of the nurses could be observed for only 4 hours each following posttraining.

A single session of training is not expected to significantly change nurses’ hand hygiene compliance rates and hand washing behaviors. In this context, longitudinal studies on the effects of longer and repeated training, observations, and evaluations could provide results that are more significant.

Another limitation of the study was that it did not use a control group and the intervention group was not randomized.

CONCLUSION The study results reveal that training in hand hygiene

improves the knowledge and attitudes of nurses regarding hand hygiene practices and hand washing techniques. The training enhanced the hand washing rates and increased the use of antiseptic hand washing products. Nurses still have problems with compliance; in fact, nurses have better hand hygiene practices than most, which is still not ideal. Frequent studies should be performed to remind nurses of the importance of hand washing.

Observing the nurses’ compliance with hand hygiene at regular intervals, using the data for performance evalu- ation, and performing clinical studies to improve hand hy-

371The Journal of Continuing Education in Nursing · Vol 49, No 8, 2018

giene among health care workers would contribute to the improvement of the hand hygiene compliance rate. Future studies could also link this process measure to the outcome measure of interest (hospital-acquired infection rates for in- fections that are linked to hand hygiene, such as central line- associated bloodstream infections and catheter-associated urinary tract infections), as well as the costs associated with hospital-acquired infections. This initiative could also be part of staff development and education program evalua- tions, with training at onboarding and on an annual basis. A quality improvement initiative that conducts periodic ob- servation audits with retraining is necessary.

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