Hand-washing is a primary component of disease
prevention. Several studies (Sharek et al., 2002, Lam et
al., 2004, Won et al., 2004) have shown that increasing
hand-washing compliance rates result in decreased rate of
communicable disease in hospital settings. However,
compliance with hand-washing protocols has been
reported in the literature as poor with high rates of
contamination (Cohen et al., 2003, Brown et al., 1996). To
improve compliance it is important to understand how
people think about hand-hygiene and the first step is to
identify the strengths and weaknesses of their education.
Infection control education varies widely between schools,
years and programs of study (Danchaivijitr et al., 2005). As
such, the purpose of this study is to identify the knowledge
and beliefs on the subject of hand-hygiene of an
interdisciplinary group of students. The specific areas of
soap/water washing, alcohol hand sanitizer and glove use
will be focused on.
Materials and Methods
Sample: Two groups were sent an email describing the
project (Queen’s Medicine, 2008 and Queen’s Nursing,
2009). In 2006/07 academic year both received hand
hygiene education and then began the clinical phase of
training. Responses were received from 39 of 79 Nursing
2009 students and 58 of 101 Medicine 2008 students.
Hand-Hygiene Education in Pre-Clinical Medical and Nursing Students
Regan Giesinger (Medicine ‘08), Robyn Duffus (Nursing ‘09)
QUIPPED Program, Queen’s University, Kingston ON
Results
97 respondents completed the survey. Of these 2 (1 Medicine, 1 Nursing) did not answer any questions and they were removed from further analysis. Of those who did answer 38 (40%) were
from Nursing 2009 and 57 (60%) were from Medicine 2008. This represents 49% and 54% response rate from Nursing and Medicine respectively. The results were divided into 3 categories
based on the subject matter of the question as follows:
Soap and Water
The choice of how much soap was needed for adequate wash
was answered similarly by both groups: 50.5% of respondents
chose enough to ‘get a lather’ and 31.6% chose ‘hands coated’
as the endpoint with no statistical difference between classes.
Figure 1: Duration of wash
70
60
50
Medicine
Nursing
40
% 30
20
10
0
10
Questionnaire: A survey was generated by the
researchers and then submitted to Dr. R. Zoutman of the
Infectious Diseases Department at Kingston General
Hospital for review. Questions were designed to test the
knowledge and beliefs of participants in the areas of
soap/water wash, alcohol sanitizer and glove use.
Administration: The survey was administered via email
using the Survey Monkey tool. Participants were sent a
request to complete the survey the day following handhygiene education and non-responders were sent a follow
up email 7 days later. The survey was closed before
formal clinical rotations began. An introduction outlined the
purpose of the questionnaire, confidentiality, and contact
information for the researchers and the Research Ethics
Board. Consent was obtained before the survey was
completed. Responses were recorded with a unique ID
and kept confidential. At the completion of the study
responses were purged from the database.
Data analysis: Results were collected and analyzed with
the assistance of Wilma Hopman, the Kingston General
Hospital Statistician.
Acknowledgments
We would like to thank the Queens Inter-professional
Patient Centered Education Directive (QUIPPED) for
funding this project.
Thank you to Dr. R. Zoutman for his input on the
questionnaire and to Wilma Hopman for her invaluable
assistance with the statistical analysis of the results.
15
30
seconds
Alcohol
Figure 2: How does alcohol compare to soap/water at
cleaning hands?
As seen in Fig. 2, Nursing tended
70
to choose alcohol as better more
60
Medicine
frequently than Medicine. The
50
Nursing
40
difference is significant (p=0.01).
% 30
Overall, >80% believe that
As can be seen in Fig.1, both
20
alcohol is at least as good as
groups tended to choose longer
10
soap and water for hand hygiene.
0
hand wash, and were both split
Better Same Worse Don't
know
between 15s and 30s. Though
there was a trend for nursing to The overwhelming majority of respondents believe that
choose 30s over 15s, there was alcohol is acceptable for emergency use (84%), not
acceptable when hands are visibly soiled (94%) and a good
no statistical significance.
alternative to soap and water (94%). With no statistically
significant differences between groups.
Glove Use
When asked if gloves were necessary for routine contact with
skin, the medicine group said they were not necessary
significantly more often (p=0.033). Both groups chose that
gloves protected both health care worker and patient >90% of
the time.
Figure 3: Gloves can be used alone as adequate hygiene.
100
80
Medicine
Nursing
60
%
40
20
0
Discussion
Hand hygiene is taught to both groups however, the timing and intensity of education is variable and neither class received evidence based
education on the subject. The Medicine students received 1 practical lab on glove use one year before clinical placement followed by a
demonstration of how to wash hands in the week before clerkship begins. Nursing students had a lecture on hand hygiene in year one
followed by a practical lab and seminar day including orientation to hand hygiene protocols of the various Kingston hospitals just before
clinical placements began. Despite these slight differences, the two groups were largely similar in their responses.
Agree
The results of gloves as a
sole hand hygiene method
can be seen in Figure 3.
Again, there is no statistical
significance, however, there
is a trend for the nursing
group to disagree.
Disagree
References
Brown J, Froese-Fretz A, Luckey D, Todd J.(1996) High rate
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Overall, neither group had a strong tendency towards one answer in any of the questions about soap and water washing. The responses
tended to be spread out over all options with larger numbers choosing more conservative answers. For example, only 3.2% of
respondents chose 10s (the shortest option) as the correct one for duration of wash and with that choice eliminated, the other options were
split approximately evenly. Similarly, few students chose the arbitrary ‘pump 3 times’ as the endpoint for how much soap was needed but
the other two choices ‘get a lather’ and ‘hands coated’ received approximately similar number of responses. This may indicate that there is
no clear message on this subject being passed on to students.
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Alcohol hand sanitizer has become a large part of the hand hygiene protocol of many health care institutions. It is now considered an
acceptable substitute for soap/water in most situations and there is evidence that alcohol is equal to traditional surgical scrub techniques
(Gupta et al., 2007). However, in this study population, 17% of students believed that alcohol was inferior to soap and water washing and
only 50% of students chose alcohol as the superior method. Additionally, nursing students had a significant edge over medicine students
in choosing correctly in this area (p=0.01). The lack of significant differences in other questions about alcohol use may reflect the fact that
though students do not know whether alcohol or soap and water is better, they do recognize that either one is better than no hand wash.
Gupta C, Czubatyj AM. Briski LE. Malani AK. (2007)
Comparison of two alcohol-based surgical scrub solutions
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effectiveness in a community hospital. Journal of Hospital
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The use of gloves without proper hand wash is a significant area of difficulty in Kingston General Hospital (Giesinger et al., 2005). It is
encouraging that most students know that gloves protect both health care worker and patient, however, in this study 32% of people
believed that gloves are acceptable as a sole method of hand hygiene. This represents a large group of new health care workers who
have not learned that gloves are not a substitute, but an adjuvant to hand washing despite education to that effect.
In general, the responses to this survey suggest that there is no clear message being sent to new health care workers on the acceptable
use of various hand hygiene methods. However, though nursing students did tend to do better in general, it was only in the use of alcohol
hand sanitizer that there was a clear difference between the two groups. Both groups of students and hand hygiene compliance in general
would likely benefit from clear, practical and easily remembered education before entering clinical placements.
Giesinger R, Nova N. and Flavin M. (2006) Hand hygiene
compliance in the Neonatal ICU. Presented: Health Sciences
Research Trainees Meeting, Queen’s University.
Lam B, Lee J, Lau Y. Hand Hygiene Practices in a Neonatal
Intensive Care Unit: A multimodal intervention and impact on
nosocomial infection.Pediatrics.2004 Nov;114(5):565-71.
Sharek JP, Benitz WE, Abel NJ, Freeburn MJ, Mayer ML,
Bergman DA. Effect of an evidence-based hand washing
policy on hand washing rates and false-positive coagulase
negative staphylococcus blood and cerebrospinal fluid culture
rates in a level III NICU. J Perinatol. 2002 Mar;22(2):137-43.
Won SP, Chou HC, Hsieh WS, Chen CY, Huang SM, Tsou KI,
Tsao PN. (2004) Handwashing program for the prevention of
nosocomial infections in a neonatal intensive care unit. Infect
Control Hosp Epidemiol. 25(9):742-6.