Citing articles

https://orcid.org/0000-0002-1009-6988

https://orcid.org/0000-0002-1744-8691

https://orcid.org/0000-0001-6229-2932

https://orcid.org/0000-0001-9061-2948

https://orcid.org/0000-0003-1337-6077

https://orcid.org/0000-0002-4750-6602

https://orcid.org/0000-0002-0202-2698

https://orcid.org/0000-0001-6458-1746

Oliveira MA de, Leuthier RM, Oliveira Filho JR, et al. Hand hygiene: knowledge and attitudes...

J Nurs UFPE on line. 2019;13:e236418

https://doi.org/10.5205/1981-8963.2019.236418

Patient safety in the scientific and care

contexts has been much discussed as a result of

adverse events observed at hospital institutions.

Hospital infections cause many deaths of

hospitalized patients, reaching 15% of hospitalized

patients in Brazil and 10% in the United States of

America and Europe.1 Healthcare-related

infections (HCRI) have increased considerably and

caused great involvement in the life of patients,

being currently considered a public health

problem. They are responsible for increasing

considerably the costs in care of the patient, in

addition to increasing the length of hospital stay,

morbidity and mortality at health services.2

One of the recommended measures to reduce

healthcare-related infections is the hand hygiene.

There are recommendations from normalizing

organs regarding products, technique, frequency,

among other aspects of the disinfection of hands,

to be followed by professionals in the health area,

which are based on the relationship between

adherence to this practice and the decrease of the

endemic rates of infection. However, adherence

to hand hygiene is still low. Therefore, the

information is not reaching its highest goal, which

is changing professionals’ behavior, which has

caused concern.3 The authors of a study carried

out in South Brazil corroborates this opinion when

stating that, although the understanding regarding

the effectiveness of hand hygiene in prevention of

infection is widespread, health professionals

inadequately adhere to this practice.4

Hands are essential tools for professionals who

develop actions at health services. Consequently,

patient safety depends directly on the adherence

to protocols of hand hygiene (HH).1 Moreover, the

behavior of health professionals regarding

microbial hazards associated with non-adherence

to hand hygiene is contradictory, being assigned to

the false perception of a risk, the underestimation

of individual responsibility and the minimization of

the problem. Furthermore, the inappropriate

behavior not always refers to the lack of

knowledge about the dangers and forms of

transmission of micro-organisms.5

Therefore, the non-hand hygiene constitutes a

serious public health problem since it leads to the

resistance of micro-organisms to pharmacological

treatments; increased hospitalization time;

increased costs to health systems and increased

mortality.4

In this context, patient safety represents a

global issue and the theme hand hygiene has been

addressed primarily in relation to attitudes that

contribute to the reduction of nosocomial

infections.1

In this context, the protocol for the Practice of

Hand Hygiene in Health Services was created,

whose purpose is to guide professionals on the

practice of hand washing and preventing the

transmission of microorganisms.8-9 This protocol

aims to advise the correct technique and five

times that health professionals should sanitize

their hands: “before touching a patient”; “before

clean/aseptic procedures”; “after body fluid

exposure/risk”; “after touching a patient” and

“after touching patient surroundings”.6-7 The

deployment of the protocol of hand hygiene is one

of the six goals recommended by the Ministry of

Health to improve patient safety in the hospital

environment.

• To assess the knowledge and understanding of

health professionals in relation to the practice of

hand hygiene

• To assess the adherence of health

professionals to the five moments of hand

hygiene.

This is a quantitative, descriptive,

observational, cross-sectional study, performed at

a philanthropic hospital in the city of João Pessoa

(PB). The data were collected during the months

of September and October of 2017.

The researchers interviewed 56 professionals

among doctors, nurses, nursing technicians and

assistants, stretcher carriers, cleaning personnel,

dieticians, pharmacists, physiotherapists,

laboratory technician, receptionists and

telemarketing. The instrument used for the survey

about the knowledge in relation to the hygiene of

hands was a self-administered questionnaire.

1 - Questionnaire to assess the knowledge on

hand hygiene.

The participants answered a basic

questionnaire adapted from the questionnaire

recommended by the World Health Organization

about the perception of health professionals about

healthcare-related infections and to hand hygiene

that addressed issues related to the perception

and knowledge of the team related to hand

hygiene, such as its importance, its efficiency and

occasions they practiced hand hygiene.

The questionnaires were applied during the

shift of professionals who were providing care

assistance in the infirmaries, which were randomly

chosen according to the availability in the service

at the application of the same, respecting the

criteria of secrecy.

2 - Questionnaire of observation of hand

hygiene

Concomitant to the application of the

questionnaire about the knowledge, the

questionnaire of observation of hand hygiene of

WHO,10 of blind nature to the team, was used in

METHOD

OBJECTIVES

INTRODUCTION

Oliveira MA de, Leuthier RM, Oliveira Filho JR, et al. Hand hygiene: knowledge and attitudes...

J Nurs UFPE on line. 2019;13:e236418

https://doi.org/10.5205/1981-8963.2019.236418

order to assess the behavior of the team in daily

clinical practice. The observation is carried out for

20 through 30 minutes, without disrupting the

activities of the professionals, registering the total

of opportunities for hand hygiene. The completed

form of opportunities includes the five moments of

hand hygiene recommended by the WHO, as

described below:

1 – Before touching a patient;

2 – Before clean/aseptic procesures;

3 – After body fluis exposure/risk;

4 – After touching a patient;

5 – After touching patient surroudings.

An opportunity of hand hygiene is an

opportunity where one of the indications for hand

hygiene is present and is observed.

The opportunity is a unit that is responsible for

the action. The need to sanitize hands is the

simple or multiple ratio (the indication that leads

to the action). It constitutes the denominator to

measure the rate of adherence to hand hygiene by

health professionals.

For each professional in observation, the

aforementioned opportunities were evaluated,

calculating the rate of compliance as follows: rate

of adherence to opportunities for hand hygiene is

equal to the number of hand hygiene actions

performed by health professionals, divided by the

number of opportunities performed for the hand

hygiene multiplied by 100.

The professionals were approached at the

hospitalization unit and, in case they accepted to

participate in the study, they were invited to go to

a reserved room to ensure privacy. The

participants signed the Informed Consent Form

(ICF), in two copies, before starting the interview,

as advocated by Resolution 466/2012, which

regulates researches involving human beings.11

This study was approved by the Research Ethics

Committee (REC) of the University Center of João

Pessoa, under Consubstantiated Opinion

1.209.075, September 1, 2017.

The collected data were entered in a database

built in Microsoft® Office Excel, analyzing them

later by means of descriptive statistics. The

proportions of affirmative answers in relation to

the total number of responses obtained in relation

to the knowledge on hand hygiene wwre

calculated, as well as the number of adherecence

to opportunities of hand hygiene in relation to the

total number of opportunities observed.

Table 1 describes the questions related to the

knowledge and perception on hand hygiene. It

shows that 100% of the interviewed professionals

considered hand hygiene important and

acknowledged the role of hands as inducing agent

of infection and that the practice of hygiene leads

to prevention of infection. Health professionals’

hands were recognized as route of transmission of

microorganisms by 94.7% of respondents; however,

36% admitted not practicing a perfect hygiene

before and after touching a patient.

Table 1. Knowledge and perception about hand hygiene of the interviewed professionals. João Pessoa (PB), Brazil, 2018.

QUESTIONS YES (%) NO (%)

Do you consider hand hygiene important? 100 - Do you consider hand hygiene efficient in the prevention of infections?

96 4.0

Are professionals’ hands routes of transmission of microorganisms?

94.7 5.3

Do you practice a perfect hand hygiene before and after touching a patient?

63.5 36.5

Does the use of na alcoholic solution (alcohol gel) facilitate hand hygiene in the work routine?

87.5 12.5

Is it necessary to sanitize the hands after touching patient surroundings?

92.5 7.5

The general rate of adherence to hand hygiene

was 8.5%, while the lower adherence observed was

the hand hygiene after touching a patient (2.1%)

(Table 2).

RESULTS

Oliveira MA de, Leuthier RM, Oliveira Filho JR, et al. Hand hygiene: knowledge and attitudes...

J Nurs UFPE on line. 2019;13:e236418

https://doi.org/10.5205/1981-8963.2019.236418

Table 2. Percentage of adherence to opportunities of hand hygiene of observed healthcare professionals. João Pessoa (PB), Brazil, 2018.

Opportunities

Adherence to hand hygiene

(N) Yes No Total

Adherence (%)

Before touching a patient 4 24 28 14 Before an invasive procedure 4 24 28 14 After fluid exposure 3 20 23 13 After taking off the gloves 2 33 35 5.7 After touching a patient 1 45 46 2.1 After touching instruments 2 42 44 4.5

Total 16 188 204 8,5

Despite the dissemination of the understanding

about the effectiveness of hand hygiene in the

prevention of infections, the adherence of

healthcare professionals to this practice is still

insufficient.4

Therefore, the deployment of protocols in the

care process becomes importante, which passes

through the follow-up of recommendations and

standardization of procedures aiming to increase

patient safety. Hand hygiene constitutes the

measure of greatest impact and proven efficacy in

the prevention of infections, and its deployment is

associated to reduced rates of infections at health

services.2

This work shows that, although the team of

professionals has an adequate perception of the

importance of hand hygiene and has knowledge in

relation to the basic concepts of hand hygiene,

this is not reflected in their work routine. One of

the great challenges in the implementation of the

protocols is the adherence of the team to the

change of the work process.

The rates of adherence to HH at health services

are low, because the general rate has been around

40%, with a variation of 5% through 81%.12-3-4

This work showed a rate around 8.5 % prior to

the implementation of a structured program of

hand hygiene. At university hospital, a research

observed a compliance rate of 27%, with the

emergency room as the area with the lowest

adherence, with a rate of 9.4%.12

The low adherence of professionals to perform

hand hygiene may not be directly associated with

the theoretical knowledge of such action, but,

rather, with the inclusion of this knowledge in

daily practice and in the daily habit of the

professional.4

In this perspective, the development of actions

aiming to continuously foster the knowledge and

practice of HH becomes important, by means of

constant educational campaigns and mobilizing

actions, being important in the perspective of

providing instruments for the health work, in order

to avoid the illness due to exposure to biological

hazards.13,15

Although the procedure of hand hygiene is

simple and low-cost, the incorporation in the daily

practice of professionals was not observed.

Nevertheless, the adoption of this practice by

health professionals is extremely important. The

change of culture relates to the offer of training,

allied to the support of the managers to this

practice.

In addition to the permanent education,

understanding and knowledge of the

organizational culture of the institution are

fundamental for adherence to protocols, since the

adherence goes through the greater involvement

of people and teams and the responsibility of each

one in the work process, facilitating change and

demonstrating improvement in the work process

and the results expected by the implementation of

protocols.12

The results show that 100% of the professionals

consider the practice of hand hygiene important,

64% stated practicing a perfect hand hygiene

before and after thouching a patient, but the

assessment of the adherence rate to hand hygiene

opportunities showed a low rate of only 8.5%.

This study shows the need for a training

program directed to professionals, which will

allow improving the knowledge about the theme,

promoting changes in habits, which, in turn, lead

to a reduced number of hospital infections.

1.Jezewski GM, Loro MM, Herr GEG, Fontana RT,

Aozane F, Santos FP, et al. Knowledge on hand

hygiene by nursing professionals from a private

hospital. Rev Cuid. 2017 Sept/Dec;8(3):1777-85.

Doi: http://dx.doi.org/10.15649/cuidarte.v8i3.419

2. Ministério da Saúde (BR), Agência Nacional de

Vigilância Sanitária, Gerência de Vigilância e

Monitoramento em Serviços de Saúde, Gerência

Geral de Tecnologia em Serviços de Saúde.

Medidas de Prevenção de Infecção Relacionada à

Assistência à Saúde [Internet]. Brasília: Ministério

da Saúde; 2017 [cited 2018 Apr 21]. Available

from:

http://portal.anvisa.gov.br/documents/33852/35

REFERENCES

CONCLUSION

DISCUSSION

http://dx.doi.org/10.15649/cuidarte.v8i3.419

http://portal.anvisa.gov.br/documents/33852/3507912/Caderno+4+-+Medidas+de+Preven%C3%A7%C3%A3o+de+Infec%C3%A7%C3%A3o+Relacionada+%C3%A0+Assist%C3%AAncia+%C3%A0+Sa%C3%BAde/a3f23dfb-2c54-4e64-881c-fccf9220c373

Oliveira MA de, Leuthier RM, Oliveira Filho JR, et al. Hand hygiene: knowledge and attitudes...

J Nurs UFPE on line. 2019;13:e236418

https://doi.org/10.5205/1981-8963.2019.236418

07912/Caderno+4+-

+Medidas+de+Preven%C3%A7%C3%A3o+de+Infec%C3

%A7%C3%A3o+Relacionada+%C3%A0+Assist%C3%AAn

cia+%C3%A0+Sa%C3%BAde/a3f23dfb-2c54-4e64-

881c-fccf9220c373

3. Ribeiro FDO, Souza MA, Paula AO, Silva AG,

Oliveira AC. Logical strategy for improving health

hygienic practices among health professionals. J

Nurs UFPE on line. 2017 Oct;11(10):3971-9. Doi:

10.5205/reuol.12834-30982-1-SM.1110201735

4. Raimondi DC, Bernal SCZ, Souza VS, Oliveira

JLC, Matsuda LM. Hand hygiene: adherence by the

nursing staff in pediatric intensive care units. Rev

Cuid. 2017 Sept;8(3):1839-48. Doi:

10.15649/cuidarte.v8i3.437

5. Oliveira AC, Gonzaga C, Costa R, Damaceno QS,

Garbaccio JL. Health care professionals’ view of

the challenges and perspectives for containing

bacterial resistance. Rev eletrônica enferm. 2013

July/Sept;15(3):745-52. Doi:

10.5216/ree.v15i3.19821

6. Ministério da Saúde (BR), Agência Nacional de

Vigilância Sanitária. Segurança do Paciente:

Higienização das mãos [Internet]. Brasília:

Ministério da Saúde; 2014 [cited 2018 Apr 15].

Available from:

https://www20.anvisa.gov.br/segurancadopacient

e/index.php/publicacoes/item/seguranca-do-

paciente-higienizacao-das-maos

7. Ministério da Saúde (BR), Agência Nacional de

Vigilância Sanitária. Protocolo para a Prática de

Higienização das Mãos em Serviços de Saúde

[Internet]. Brasília: Ministério da Saúde; 2013

[cited 2018 Apr 05]. Available from:

https://www20.anvisa.gov.br/segurancadopacient

e/index.php/publicacoes/item/higiene-das-maos

8. Ministério da Saúde (BR), Gabinete do Ministro.

Portaria 1377, de 9 de julho de 2013. Aprova os

protocolos de Segurança do Paciente [Internet].

Brasília: Ministério da Saúde; 2013 [cited 2018 Apr

05]. Available from:

http://bvsms.saude.gov.br/bvs/saudelegis/gm/20

13/prt1377_09_07_2013.html

9. Ministério da Saúde (BR), Ministério do

Gabinete. Portaria 2.095, de 24 de setembro de

2013. Aprova os Protocolos Básicos de Segurança

do Paciente [Internet]. Brasília: Ministério da

Saúde; 2013 [cited 2018 Apr 05]. Available from:

http://bvsms.saude.gov.br/bvs/saudelegis/gm/20

13/prt2095_24_09_2013.html

10. Organização Pan-Americana da Saúde. Manual

para observadores: estratégia multimodal da OMS

para a melhoria da higienização das mãos

[Internet]. Brasília: OPAS; 2008 [cited 2018 Apr

01]. Available from:

https://www.paho.org/bra/index.php?option=com

_docman&view=download&alias=497-manual-para-

observadores-7&category_slug=seguranca-do-

paciente-970&Itemid=965

11. Ministério da Saúde (BR), Conselho Nacional

de Saúde. Resolução nº 466, de 12 dez 2012.

Diretrizes e normas regulamentadoras sobre

pesquisa envolvendo seres humanos [Internet].

Brasília: Ministério da Saúde; 2012 [cited 2018 Apr

15]. Available from:

http://bvsms.saude.gov.br/bvs/saudelegis/cns/20

13/res0466_12_12_2012.html

12. Kawamoto AM, Oliveira JLC, Tonini NS, Nicola

AL. Leadership and patient safety culture:

perceptions of professionals in a university

hospital. J res fundam care online. 2016 Apr;

2(4):387-439. Doi: 10.9789/2175-

5361.2016.v8i2.4387-4398

13. Oliveira AC, Paula AO, Gama CS. Monitoring

hand hygiene: direct observation versus self-report

rates. Enferm glob. 2017 Oct; 16(48):324-53. Doi:

http://dx.doi.org/10.6018/eglobal.16.4.277861

14. Boyce JM, Pittet D. Guideline for hand hygiene

in health-care settings: recommendations of the

health care settings: recommendations of the

health care infection control practices advisory

committee and the HICPAC/ SHEA/ APIC/IDSA

hand hygiene task force. MMWR recomm rep

[Internet]. 2002 Oct [cited 2018 Apr 15];51(RR-

16):1-44. Available from:

https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

15. Silva DS, Dourado AAG, Cerqueira CRE, Romero

FH, Amaral NA, Pearce PF, et al. Hand hygiene

adherence according to World Health Organization

Recommendations in a Neonatal Intensive Care

Unit. Rev Bras Saúde Mater Infant [Internet]. 2017

July/Sept [cited 2018 Apr 21];17(3):551-9. Doi:

http://dx.doi.org/10.1590/1806-

93042017000300008

Submission: 2019/05/10 Accepted: 2019/04/17 Publishing: 2019/06/27

Corresponding Address

Maria Amanda Pereira Leite

Email: [email protected]

All the contents of this article is licensed under a Creative Commons Atribuição 4.0 Internacional

https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/seguranca-do-paciente-higienizacao-das-maos

https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/item/higiene-das-maos

http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt1377_09_07_2013.html

http://bvsms.saude.gov.br/bvs/saudelegis/gm/2013/prt2095_24_09_2013.html

https://www.paho.org/bra/index.php?option=com_docman&view=download&alias=497-manual-para-observadores-7&category_slug=seguranca-do-paciente-970&Itemid=965

http://bvsms.saude.gov.br/bvs/saudelegis/cns/2013/res0466_12_12_2012.html

http://dx.doi.org/10.6018/eglobal.16.4.277861

https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

http://dx.doi.org/10.1590/1806-93042017000300008