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Exploring the hand hygiene competence of student nurses: A case of flawed self assessment
Nurse Education Today (2009) 29, 380–388
Nurse Education Today www.elsevier.com/nedt
Exploring the hand hygiene competence of student nurses: A case of flawed self assessment Mark Cole
*
School of Nursing, University of Nottingham, Grantham and District Hospital, Grantham, Lincolnshire NG31 8DG, United Kingdom Accepted 18 October 2008
KEYWORDS
Summary Hand hygiene remains the single most effective measure to prevent hospital acquired infection and yet poor compliance is reported repeatedly. Nurses represent the largest labour group and perform the greatest amount of direct patient care in the contemporary National Health Service. They receive their initial hand hygiene training in the pre-registration curriculum within a competence framework based on knowledge, skills and attitudes. The pre-eminent training method is one that delivers behavioural competence, making the tacit assumption that compliance will follow. In this study a mixed methods approach demonstrated that students overestimated their knowledge and skills, found it difficult to give an objective account of their performance, and reported an improbable level of compliance. The reasons why people can be self serving in their judgements may be due to information processing errors, exacerbated by the model of education and training. Flawed self assessments may present major barriers to improved performance if students view their compliance as better than it actually is. Conceptualising hand hygiene as a taxonomy of learning and introducing the cognitive strategies of reflection and self assessment would better enable students to problem solve, seek out new information, draw on past experience and gain greater and deeper understanding of the complex topic of hand hygiene behaviour. c 2008 Elsevier Ltd. All rights reserved.
Hand hygiene; Competence; Education and training; Flawed self assessment
Introduction and background Hand hygiene remains the single most effective measure to prevent Hospital Acquired Infection (Hass and Larson, 2007; Department of Health, * Tel.: +44 1476 565232x4309. E-mail address: [email protected]
2003; Pratt et al., 2001). It has spawned a plethora of research (Whitby et al., 2006; Creedon, 2005; McGukin, 2004; Bischoff et al., 2000) and has been referred to as both a simple mechanical task (Paotong et al., 2003; Fell, 2000) and a complex behavioural phenomenon (Pittet, 2004). Its importance does not appear to be sufficiently recognised by health care workers (Pittet, 2004; Fell, 2000),
0260-6917/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.10.010
Exploring the hand hygiene competence of student nurses: A case of flawed self assessment and poor compliance has been documented repeatedly (Randle et al., 2007; Gould et al., 2007; Huggonet et al., 2002; Pittet, 2001; Pittet et al., 1999). Multi-modal hand hygiene campaigns have been recommended and initiated (Store and ClaytonKent, 2004) and although some interventions to improve compliance have been successful, few seem to be associated with lasting improvement (Boyce and Pittet, 2002; Pittet et al., 2000; Farr, 2000). While education is seen as the cornerstone of effective practice (Elliott, 2003) this is increasingly delivered to student nurses, through a competency based approach which has surfaced as a key policy development in industrialised nations (Cowan et al., 2005). Nevertheless, clinical competence and its assessment are contentious issues (Clinton et al., 2005). The concept is complex, political and often misunderstood (Watson, 2002) and can be ambiguous and confusing (Meretoja et al., 2004). While some see it as the ability to demonstrate an appropriate level of professional practice in a variety of contexts (Levett-Jones, 2007) others see it as a reductionist process that is used to describe an action, behaviour or outcome in a form that is capable of demonstration, observation and assessment (McMullan et al., 2003). Traditionally hand hygiene educators have employed didactic methods to teach indicative content (Sax et al., 2007) and have assessed technical competence through behavioural outcomes, using practical strategies such as objective structured clinical examinations (OSCEs) (Rushforth, 2007; Brosnan et al., 2006; Morrison and Stewart, 2005). Advocates argue OSCE’s provide a reliable, objective method of assessment which simulates the practice setting (Major, 2005; Hinchliff, 2004). Critics counter that they re-enforce a behavioural view of competence that considers the technical skill at the expense of knowledge and understanding (McMullan et al., 2003; Fordham, 2005). Although the notion of hand hygiene performance as a complex multifarious activity is gaining increasing acceptance (Mah, 2006; Cole, 2006; Store and Clayton-Kent, 2004; Pittet, 2004, Jenner, 2002; O’Boyle et al., 2001), the behaviourist model of teaching remains dominant and insidiously influential in higher education (Maclellan, 2005). This may be a pragmatic response to increasing student/staff ratios, diversity of student types and the legacy systems of time tabling and assessment; or the recognition that behavioural strategies are an efficient way of bringing students to a high level of performance in a short period of time, using time effectively and recording a high level of satisfaction (Dunning et al., 2004). How-
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ever, the use of a behavioural model might mistake the student’s short-term excellence for their longterm competence, leaving them potentially overconfident in their knowledge and ability (Dunning, 2005). A feature of hand hygiene studies are that nurses not only overestimate their personal compliance (Jenner et al., 2006) but express dissonance between what that say, what they know, and what they do (Creedon, 2005; O’Boyle et al., 2001). This purpose of this study was to explore the phenomenon of self assessed hand hygiene behaviour among student nurses, consider how this may impact on their practice and suggest educational strategies that may help to develop their insight and performance.
Methodology Design A methodological triangulation (Shih, 1998; Dootson, 1995) which combined two data collection procedures, a questionnaire and interview was the chosen method for this study. Methodological triangulation is ideally suited when studying complex concepts, like attitude and behaviour that may contain many dimensions ( Begley, 1996). Advocates of mixed methods argue that all research approaches are designed to understand and explain behaviour and events, their components, antecedents, corollaries, and consequences (Dzurec and Abraham, 1993). Therefore, blending elements of one with the other is possible, especially if the approaches have similar axiologies (Lincoln and Gubba, 2000). It has been reported that health care workers systematically overestimate their hand hygiene compliance (Hass and Larson, 2007). A possible reason for this relates to the cognitive problems associated with objective self assessment (Augoustinos et al., 2006). A questionnaire which was superficial, easy to complete and required answers without justification, was considered the best way to capture this phenomenon. By contrast, an interview schedule would require a greater degree of reflection and in essence, a more considered response. The potential for discrepancy between the instinctive/reflective, subjective/ objective, underpins this study.
Ethics Ethical approval for the study was gained from the universities research and ethics committee. Cohorts were seen over a two month period, the study was explained and the questionnaire distributed. It
382 was anonymous and completion was voluntary. The ethics committee had greater concern in relation to the interview schedule and raised issues including power, obligation and coercion. At the committees request students were only recruited through response to a poster which was located in two schools of nursing. Consent forms were signed by those who took part in the interview phase.
Sampling The sample for the questionnaire component was the five senior cohorts in the diploma of nursing programme. The junior cohort was excluded as they had not entered clinical practice. The response rate among groups ranged from 77.4% to 92.5% with a mean of 83.5%. (N = 147). In the interview phase 14 students (9.52%) who were a part of the original sample, responded to the poster. All branches of nursing were represented in both components of the study and all had received hand hygiene training. All students had been assessed as competent hand washers through the universities internal summative assessment procedures.
Instruments Editorial permission was given to reproduce a questionnaire devised by (Pittet et al., 2004) which followed guidelines from social cognitive theories applied to health-related behaviours. A 7-point scale assessed cognitive factors, that is, intention to adhere to hand hygiene, perception of knowledge of hand hygiene indications, attitude toward hand hygiene, perception of social norms concerning hand hygiene (both behavioural and subjective norms), perception of difficulty of adhering to hand hygiene, and perception of the risk for cross-transmission linked to non-adherence. Motivation to improve hand hygiene was assessed by using a 3-point scale. Knowledge of hand hygiene indications for four types of contact was recorded according to standard definitions (Boyce and Pittet, 2002). To gain a deeper understanding of the participants’ responses a semi-structured one-to-one personal interview schedule was developed for the qualitative phase. The questions were similar to those asked in the interview. However, the creation of an open situation, allowed the interviewee the freedom to introduce additional information that they might feel important. Interviews took place in the school of nursing, were undertaken by the single researcher, audio taped, transcribed verbatim and sent to the interviewee for member checking.
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Data analysis procedures The quantitative data from the questionnaire were analyzed using the Statistical Package for the Social Sciences (SPSS version 14). Descriptive statistics such as percentage, mode, mean and standard deviation were used to calculate the overall values for each dimension. These were used as a basis for exploration in the interview phase where Neuman’s (2002) five point plan for creating themes in qualitative analysis was used to conduct content analysis.
Results Quantitative All scores with the exception of one were subject to a seven point likert scale, with seven being the highest possible score. The mode was used to highlight the most common answer (Table 1). Although crude, the results appear to confirm the theory that health care workers do not make objective self assessments in relation to their hand hygiene compliance (Jenner et al., 2006). A mode of 7 in relation to personal compliance is discordant with compliance rates reported from observational studies (Creedon, 2005). Trunnel and White (2005) question whether over reporting is a result of a lack of candour, or more likely, self deception. Respondents went on to consistently report a higher level of compliance, mode 7, than that of their colleagues, mode 5.76% of the sample considered their compliance superior to that of their colleagues. This result is consistent with studies that suggest individuals over estimate their own levels of compliance but correctly estimate the compliance of their peers (Snow and White, 2006). Knowledge of guidelines was reported as high with a mode 7; however, compliance in accordance with different care activities all of which are indicated through hand hygiene guidelines, received different distributions. 93.8% of respondents gave a score of 7 for ‘‘following contact with body fluids’’. However this fell to 40/8% ‘‘following glove usage’’. Whether respondents overestimated their level of knowledge or disagree with guidelines is unclear, however, findings by Flores and Prevalin, (2006) indicates that hand hygiene compliance is affected by the use of glove. When asked whether they could improve their hand hygiene behaviour 90.5% answered either yes or possibly, despite reporting existing levels of unlikely compliance. The results of the quantitative phase (Appendix 1) are consistent with those reported
Exploring the hand hygiene competence of student nurses: A case of flawed self assessment Table 1
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Results from Hand Hygiene questionnaire.
in the literature, that clinicians self-report a very high rate of personal compliance (Jenner et al., 2006).
Qualitative Respondents were asked to elaborate on the answers that they gave in the questionnaire and discuss the factors that influenced their compliance. Respondents chose to, although not asked, to focus on positive aspects. Initially two main motivational themes emerged, internal factors and external factors.
Internal factors Respondents spoke of a professional duty and moral obligation to maintain high standards. Farr (2000) suggests that failure to comply with policies may reflect personalities in which the ID (that segment of personality concerned with one’s own personal pleasure, predominates over the super ego (that segment of personality concerned with moral values). Non-compliance tends to focus on blame and moral responsibility (Farr, 2000) and a number of writers have been overtly critical of hand hygiene standards (Larson, 2005; Huskins and Gold-
mann, 2005; Weinstein, 2004). As hand hygiene is an act that benefits someone else, perhaps it is logical that messages should invoke a sense of personal responsibility and an appeal to altruistic behaviour (Jenner and Jones, 2005). ‘‘It’s a basic function; part and parcel of who you are. By not washing your hands, of course you are letting the patient down, but you are letting yourself down as well. It might be a ´ but it is important to know that you have cliche done the right things before I go home. It’s about professional pride.’’ ‘‘My hands might be cracked and sore but it does not stop me from washing them. At the end of the day we are here for the patient, you make sacrifices.’’
External factors When discussing their external influences three areas were commonly discussed; the impact of the OSCE, cues to action in clinical practice and the behaviour of role models. Education is commonly cited as the cornerstone of effective practice (Elliott, 2003). Multi model hand hygiene campaigns are based, in essence, around cues to action such as cartoon or high impact posters, near
384 patient alcohol hand rubs and audits of practice (Whitby et al., 2006). The importance of positive and negative role models is well documented (Lankford, 2003; Salemi, 2002; Stone et al., 2001) although in this study respondents believed that they modelled good compliance, but poor compliance had little impact on their behaviour. ‘‘I think my compliance was particularly good in the first year just after we had our training and passed our OSCE. Training acts as a reminder, it brings things to the forefront of your mind.’’ ‘‘Mentors behaviour is a factor, after all they are teaching you. I remember thinking in my current placement everyone is washing their hands, it definitely has an impact. There is poor practice as well but you just rise above that.’’ At this point additional information was introduced to challenge the underpinnings of the students self-reports. Before 1995 the Centre for Disease Control and Prevention Guidelines on hand washing explicitly stated that hand cleansing was not necessary after all patient contacts, but merely after prolonged ones. This changed in 1995 because of the increasing incidence of antimicrobial resistant pathogens spread through hands (Elliott, 2003). However, applying this in acute settings could generate up to 40 Hand Hygiene episodes, per single patient, per hour (Gould, 2004). To attain full compliance staff may have to decontaminate their hands in excess of 100 times in a single shift (Vandenbrouke-Grauls, 2000). Boyce (2001) calculated that on a 12 bedded intensive care unit hand washing would require 16 h of nursing time per shift. Students were asked to consider these figures and hand hygiene in relation to all care episodes. Two further themes emerged real world compliance and flawed self assessment.
Real world compliance ‘‘I am shocked. I do not think those figures are very realistic. In today’s health care, time is precious; despite best intentions, there are so many other things to do. It is not just about time though, the state of someone’s hands, what would they be like?’’ ‘‘You cannot wash your hands that many times. You consciously or subconsciously develop a hierarchy and see some jobs as higher risk than others. You instinctively wash you hands after things like handling body fluids or treating someone who has MRSA, because people can
M. Cole see, feel and know the risk. But social care, I have never seen it and I have never done it.’’ Students were asked how they reconciled their shock of these figures and their reporting of excellent knowledge and excellent standards.
Unrealistic optimism ‘‘Although I was shocked, I probably shouldn’t be. I know what the guidelines say and I know what I should do. But guidelines are a gold standard, they are aspirational. We talk about evidence based practice but I think it is a human characteristic to pick and chose some of your evidence.’’ ‘‘It’s complicated; you always overestimate your ability and ignore your deficiencies. It’s a self image thing; hand washing is very big at the moment. You would have to be very brave to say you don’t do it, that would be a terrible loss of face; you just couldn’t say it.’’
Discussion In the quantitative phase of the study respondents reported a positive attitude and high self evaluation of their hand hygiene behaviour. Although no attempt was made to observe their behaviour this is consistent with the notions of high self assessment and over reporting that are well established in the literature (O’Boyle et al., 2001; Alexander and Sirotnak, 1997; Larson et al., 1997; Tibballs, 1996 Alvaran et al., 1994; Henry et al., 1994). When researchers correlate self assessment of knowledge and skill against objective performance, the relationship they find is rarely strong (Chemers et al., 2001; Stajkovic and Luchins, 1998; DePaulo et al., 1997). Jenner et al. (2006) suggests self reporting in relation to hand hygiene is so unreliable it should only be used with extreme caution. When additional cognitive information was introduced during the qualitative phase, respondents were surprised and then became more candid.
Unrealistic optimism Unrealistic optimism refers to the notion that people systematically overestimate the probability that good things will happen to them and underestimate the probability that bad things will happen (Weinstein, 1980). A recent review found that this phenomenon is extremely robust and not limited by demographics such as age, sex, education or occu-
Exploring the hand hygiene competence of student nurses: A case of flawed self assessment pation (Wenglert and Rosen, 2000).The reasons why people can be self serving in their judgements, leading to flawed self assessments can be explained by the fact that, firstly people are motivated to present a positive view of themselves and secondly they make systematic information processing errors when analyzing situations (Dunning, 2005).
Self-esteem Optimistic biases can derive from motivational causes such as a need to protect self, self-esteem and preventing anxiety (Boney-McCoy et al., 1999; Gerrard et al., 1996; Croyle et al., 1993). Self evaluation is not a cold cognitive process, involving objective compilation of information; rather, it is influenced by the motivations that lead people to evaluate themselves in the first place (Taylor and Nester, 1995). This influences the way in which people seek out, attend to, recall and attribute information about themselves (Gross, 2005). Good hand hygiene is commonly perceived as an important and fundamental nursing skill (Pratt et al., 2001) a simple task (Babacombe, 2004) and a measure that prevents morbidity and mortality in patients (Department of Health, 2003). If as some suggest, high occupational self-esteem is important (Randle, 2003) it may be problematic and damaging to the occupational self-esteem of health care staff to admit that they are poor hand washing compliers.
Information processing errors Cognitive explanations of unrealistic optimism are based on the assumptions that people make systematic information processing errors when analyzing situations (Dunning et al., 2004). Two important components are the above average effect the notion that people tend to believe that they are above average (Clarke et al., 2000) and the overconfidence effect that people place too much confidence in the insightfulness of their judgements (Oksam, 2000). None of the respondents in this study saw themselves as average and reported scores higher than those of their colleagues. All respondents reported a high knowledge of guidelines although no one had actually read them. It is posited in this study that although the behavioural educational strategies pre-eminent in hand hygiene education (Sax et al., 2007) make a significant contribution to the development of practice, they may exacerbate problems of objective self assessment, and as such, have a negative influence on practice. Within a taxonomy of learn-
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ing, strategies need to be introduced into the nursing curriculum that develop the cognitive process dimension and build on the student’s knowledge and skills in order to develop understanding and insight.
Future educational strategies The ability to accurately self assess ones competence and achievements is not a natural gift, but rather, a skill that can be learned, improved on and excelled in (Mattheos et al., 2004). Moreover, skills that engender competence are the same skills that are required to evaluate competency (Kruger, 1999). One of the aims of a nursing curriculum should be to ensure that students are competent not only in a clinical procedure like hand washing, but also in their ability to constructively assess themselves. There is a sense that self assessment is synonymous with reflection (Price, 2005) and nurses should use both as a continuous part of their professional work and learning (Ekebergh et al., 2004; Thorpe, 2004). Reflection requires the individual to be self aware and have an ability to analyze knowledge to develop newer and deeper perspectives (Halford and Leonard, 2003). Synthesis and evaluation of new ideas, concepts and/or mind sets may emerge resulting in altered ways of caring and maintaining performance (Simmonds, 2003). Self-assessment through reflection would allow the student to consider their practice within the clinical environment and gain insight into their performance in order to identify strengths and areas for further development (Campbell and Mackay, 2001; Hannigan, 2001). Reflective practice has a role to play at all stages of the ‘novice to expert’ continuum (Paget, 2001) and there are a number of techniques cited in the literature including critical incidents, supervision and reflective journals for doing this (Hargreaves, 2004). Journal writing is a technique that has long been advocated (Kessler, 2004; Williams et al., 2000; Boud et al., 1985) as it said to enhance self-awareness, interpersonal understanding, critical analysis, cognitive learning and clinical reasoning skills (Chirema, 2007). Although clearly time consuming, journal writing is a technique worthy of further consideration. In her study Larson et al. (2004) used diary cards as a strategy for nurses to self assess their hand hygiene behaviour and minimize the problem of recall bias. I believe this could be used more widely to support and enhance the established behavioural methods of teaching. A common theme to emerge in this study is that when asked, none of the respondents felt confident to estimate or quantify
386 their hand washing performance. More typically students would volunteer ‘‘I don’t know how many times, I couldn’t put a number on it, but I know it’s a lot’’. The availability heuristic posits that categorical judgements are easily influenced by how easily similar examples can be retrieved from the memory (Buckingham and Adams, 2000). As such students may find it easy to recall the times they washed their hands rather than the times they did not, and therefore exacerbate the problems of objective self assessment. Asking students to reflect upon their performance, and importantly record it, could be one method of facilitating greater insight and prove fertile grounds for discussion through critical analysis. Similarly this could be extended by asking students to consider different levels of compliance before and after different types of activities or different performance levels in relation to different shift patterns. This type of data is sadly lacking and this study suggests that students rarely consider the salience of these factors.
Conclusion The word competence is used extensively in nursing education and is gaining international recognition as a means of developing the clinical skills that are a critical component of any undergraduate nursing programme. Hand hygiene is considered a core skill, that can have an enormous impact on the morbidity and mortality associated with hospital acquired infection. Although presented as a simple, mechanical procedure, compliance associated with hand hygiene is in fact complex and incorporates knowledge and behaviours at many levels. While the term competence may include caveats that encourage educationalists to view it in a multi-faceted, holistic way, the pre-eminent model for hand hygiene training remains didactic, performance based and outcome driven. Though this model has been extremely successful at developing practice through the acquisition of knowledge and psychomotor skills, because of its perceived importance, staff feel compelled to report an unlikely level of compliance. Moreover, as self assessment is synonymous with over reporting it has been largely discredited within hand hygiene research. Nevertheless, it is plausible that flawed self assessments are not the result of dishonesty but the consequence of an inability to objectively self assess. Rather than rejecting the notion it is posited that self assessment is a fundamental component of hand hygiene competence. Learnt skills and
M. Cole motivation to improve will be mediated by how individuals see their current practice. Behavioural educational strategies have their place and are an important approach to teach underpinning principles, at an early stage in an undergraduate programme. However, a taxonomy should be developed that revisits the topic and challenges common assumptions about practice. Cognitive strategies that require students to reflect on their practice and objectively assess their own performance may better enable them to problem solve, seek out new information, draw on past experience and gain a greater and deeper understanding of complex compliance issues.
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Exploring the hand hygiene competence of student nurses: A case of flawed self assessment Mark Cole
*
School of Nursing, University of Nottingham, Grantham and District Hospital, Grantham, Lincolnshire NG31 8DG, United Kingdom Accepted 18 October 2008
KEYWORDS
Summary Hand hygiene remains the single most effective measure to prevent hospital acquired infection and yet poor compliance is reported repeatedly. Nurses represent the largest labour group and perform the greatest amount of direct patient care in the contemporary National Health Service. They receive their initial hand hygiene training in the pre-registration curriculum within a competence framework based on knowledge, skills and attitudes. The pre-eminent training method is one that delivers behavioural competence, making the tacit assumption that compliance will follow. In this study a mixed methods approach demonstrated that students overestimated their knowledge and skills, found it difficult to give an objective account of their performance, and reported an improbable level of compliance. The reasons why people can be self serving in their judgements may be due to information processing errors, exacerbated by the model of education and training. Flawed self assessments may present major barriers to improved performance if students view their compliance as better than it actually is. Conceptualising hand hygiene as a taxonomy of learning and introducing the cognitive strategies of reflection and self assessment would better enable students to problem solve, seek out new information, draw on past experience and gain greater and deeper understanding of the complex topic of hand hygiene behaviour. c 2008 Elsevier Ltd. All rights reserved.
Hand hygiene; Competence; Education and training; Flawed self assessment
Introduction and background Hand hygiene remains the single most effective measure to prevent Hospital Acquired Infection (Hass and Larson, 2007; Department of Health, * Tel.: +44 1476 565232x4309. E-mail address: [email protected]
2003; Pratt et al., 2001). It has spawned a plethora of research (Whitby et al., 2006; Creedon, 2005; McGukin, 2004; Bischoff et al., 2000) and has been referred to as both a simple mechanical task (Paotong et al., 2003; Fell, 2000) and a complex behavioural phenomenon (Pittet, 2004). Its importance does not appear to be sufficiently recognised by health care workers (Pittet, 2004; Fell, 2000),
0260-6917/$ - see front matter c 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2008.10.010
Exploring the hand hygiene competence of student nurses: A case of flawed self assessment and poor compliance has been documented repeatedly (Randle et al., 2007; Gould et al., 2007; Huggonet et al., 2002; Pittet, 2001; Pittet et al., 1999). Multi-modal hand hygiene campaigns have been recommended and initiated (Store and ClaytonKent, 2004) and although some interventions to improve compliance have been successful, few seem to be associated with lasting improvement (Boyce and Pittet, 2002; Pittet et al., 2000; Farr, 2000). While education is seen as the cornerstone of effective practice (Elliott, 2003) this is increasingly delivered to student nurses, through a competency based approach which has surfaced as a key policy development in industrialised nations (Cowan et al., 2005). Nevertheless, clinical competence and its assessment are contentious issues (Clinton et al., 2005). The concept is complex, political and often misunderstood (Watson, 2002) and can be ambiguous and confusing (Meretoja et al., 2004). While some see it as the ability to demonstrate an appropriate level of professional practice in a variety of contexts (Levett-Jones, 2007) others see it as a reductionist process that is used to describe an action, behaviour or outcome in a form that is capable of demonstration, observation and assessment (McMullan et al., 2003). Traditionally hand hygiene educators have employed didactic methods to teach indicative content (Sax et al., 2007) and have assessed technical competence through behavioural outcomes, using practical strategies such as objective structured clinical examinations (OSCEs) (Rushforth, 2007; Brosnan et al., 2006; Morrison and Stewart, 2005). Advocates argue OSCE’s provide a reliable, objective method of assessment which simulates the practice setting (Major, 2005; Hinchliff, 2004). Critics counter that they re-enforce a behavioural view of competence that considers the technical skill at the expense of knowledge and understanding (McMullan et al., 2003; Fordham, 2005). Although the notion of hand hygiene performance as a complex multifarious activity is gaining increasing acceptance (Mah, 2006; Cole, 2006; Store and Clayton-Kent, 2004; Pittet, 2004, Jenner, 2002; O’Boyle et al., 2001), the behaviourist model of teaching remains dominant and insidiously influential in higher education (Maclellan, 2005). This may be a pragmatic response to increasing student/staff ratios, diversity of student types and the legacy systems of time tabling and assessment; or the recognition that behavioural strategies are an efficient way of bringing students to a high level of performance in a short period of time, using time effectively and recording a high level of satisfaction (Dunning et al., 2004). How-
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ever, the use of a behavioural model might mistake the student’s short-term excellence for their longterm competence, leaving them potentially overconfident in their knowledge and ability (Dunning, 2005). A feature of hand hygiene studies are that nurses not only overestimate their personal compliance (Jenner et al., 2006) but express dissonance between what that say, what they know, and what they do (Creedon, 2005; O’Boyle et al., 2001). This purpose of this study was to explore the phenomenon of self assessed hand hygiene behaviour among student nurses, consider how this may impact on their practice and suggest educational strategies that may help to develop their insight and performance.
Methodology Design A methodological triangulation (Shih, 1998; Dootson, 1995) which combined two data collection procedures, a questionnaire and interview was the chosen method for this study. Methodological triangulation is ideally suited when studying complex concepts, like attitude and behaviour that may contain many dimensions ( Begley, 1996). Advocates of mixed methods argue that all research approaches are designed to understand and explain behaviour and events, their components, antecedents, corollaries, and consequences (Dzurec and Abraham, 1993). Therefore, blending elements of one with the other is possible, especially if the approaches have similar axiologies (Lincoln and Gubba, 2000). It has been reported that health care workers systematically overestimate their hand hygiene compliance (Hass and Larson, 2007). A possible reason for this relates to the cognitive problems associated with objective self assessment (Augoustinos et al., 2006). A questionnaire which was superficial, easy to complete and required answers without justification, was considered the best way to capture this phenomenon. By contrast, an interview schedule would require a greater degree of reflection and in essence, a more considered response. The potential for discrepancy between the instinctive/reflective, subjective/ objective, underpins this study.
Ethics Ethical approval for the study was gained from the universities research and ethics committee. Cohorts were seen over a two month period, the study was explained and the questionnaire distributed. It
382 was anonymous and completion was voluntary. The ethics committee had greater concern in relation to the interview schedule and raised issues including power, obligation and coercion. At the committees request students were only recruited through response to a poster which was located in two schools of nursing. Consent forms were signed by those who took part in the interview phase.
Sampling The sample for the questionnaire component was the five senior cohorts in the diploma of nursing programme. The junior cohort was excluded as they had not entered clinical practice. The response rate among groups ranged from 77.4% to 92.5% with a mean of 83.5%. (N = 147). In the interview phase 14 students (9.52%) who were a part of the original sample, responded to the poster. All branches of nursing were represented in both components of the study and all had received hand hygiene training. All students had been assessed as competent hand washers through the universities internal summative assessment procedures.
Instruments Editorial permission was given to reproduce a questionnaire devised by (Pittet et al., 2004) which followed guidelines from social cognitive theories applied to health-related behaviours. A 7-point scale assessed cognitive factors, that is, intention to adhere to hand hygiene, perception of knowledge of hand hygiene indications, attitude toward hand hygiene, perception of social norms concerning hand hygiene (both behavioural and subjective norms), perception of difficulty of adhering to hand hygiene, and perception of the risk for cross-transmission linked to non-adherence. Motivation to improve hand hygiene was assessed by using a 3-point scale. Knowledge of hand hygiene indications for four types of contact was recorded according to standard definitions (Boyce and Pittet, 2002). To gain a deeper understanding of the participants’ responses a semi-structured one-to-one personal interview schedule was developed for the qualitative phase. The questions were similar to those asked in the interview. However, the creation of an open situation, allowed the interviewee the freedom to introduce additional information that they might feel important. Interviews took place in the school of nursing, were undertaken by the single researcher, audio taped, transcribed verbatim and sent to the interviewee for member checking.
M. Cole
Data analysis procedures The quantitative data from the questionnaire were analyzed using the Statistical Package for the Social Sciences (SPSS version 14). Descriptive statistics such as percentage, mode, mean and standard deviation were used to calculate the overall values for each dimension. These were used as a basis for exploration in the interview phase where Neuman’s (2002) five point plan for creating themes in qualitative analysis was used to conduct content analysis.
Results Quantitative All scores with the exception of one were subject to a seven point likert scale, with seven being the highest possible score. The mode was used to highlight the most common answer (Table 1). Although crude, the results appear to confirm the theory that health care workers do not make objective self assessments in relation to their hand hygiene compliance (Jenner et al., 2006). A mode of 7 in relation to personal compliance is discordant with compliance rates reported from observational studies (Creedon, 2005). Trunnel and White (2005) question whether over reporting is a result of a lack of candour, or more likely, self deception. Respondents went on to consistently report a higher level of compliance, mode 7, than that of their colleagues, mode 5.76% of the sample considered their compliance superior to that of their colleagues. This result is consistent with studies that suggest individuals over estimate their own levels of compliance but correctly estimate the compliance of their peers (Snow and White, 2006). Knowledge of guidelines was reported as high with a mode 7; however, compliance in accordance with different care activities all of which are indicated through hand hygiene guidelines, received different distributions. 93.8% of respondents gave a score of 7 for ‘‘following contact with body fluids’’. However this fell to 40/8% ‘‘following glove usage’’. Whether respondents overestimated their level of knowledge or disagree with guidelines is unclear, however, findings by Flores and Prevalin, (2006) indicates that hand hygiene compliance is affected by the use of glove. When asked whether they could improve their hand hygiene behaviour 90.5% answered either yes or possibly, despite reporting existing levels of unlikely compliance. The results of the quantitative phase (Appendix 1) are consistent with those reported
Exploring the hand hygiene competence of student nurses: A case of flawed self assessment Table 1
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Results from Hand Hygiene questionnaire.
in the literature, that clinicians self-report a very high rate of personal compliance (Jenner et al., 2006).
Qualitative Respondents were asked to elaborate on the answers that they gave in the questionnaire and discuss the factors that influenced their compliance. Respondents chose to, although not asked, to focus on positive aspects. Initially two main motivational themes emerged, internal factors and external factors.
Internal factors Respondents spoke of a professional duty and moral obligation to maintain high standards. Farr (2000) suggests that failure to comply with policies may reflect personalities in which the ID (that segment of personality concerned with one’s own personal pleasure, predominates over the super ego (that segment of personality concerned with moral values). Non-compliance tends to focus on blame and moral responsibility (Farr, 2000) and a number of writers have been overtly critical of hand hygiene standards (Larson, 2005; Huskins and Gold-
mann, 2005; Weinstein, 2004). As hand hygiene is an act that benefits someone else, perhaps it is logical that messages should invoke a sense of personal responsibility and an appeal to altruistic behaviour (Jenner and Jones, 2005). ‘‘It’s a basic function; part and parcel of who you are. By not washing your hands, of course you are letting the patient down, but you are letting yourself down as well. It might be a ´ but it is important to know that you have cliche done the right things before I go home. It’s about professional pride.’’ ‘‘My hands might be cracked and sore but it does not stop me from washing them. At the end of the day we are here for the patient, you make sacrifices.’’
External factors When discussing their external influences three areas were commonly discussed; the impact of the OSCE, cues to action in clinical practice and the behaviour of role models. Education is commonly cited as the cornerstone of effective practice (Elliott, 2003). Multi model hand hygiene campaigns are based, in essence, around cues to action such as cartoon or high impact posters, near
384 patient alcohol hand rubs and audits of practice (Whitby et al., 2006). The importance of positive and negative role models is well documented (Lankford, 2003; Salemi, 2002; Stone et al., 2001) although in this study respondents believed that they modelled good compliance, but poor compliance had little impact on their behaviour. ‘‘I think my compliance was particularly good in the first year just after we had our training and passed our OSCE. Training acts as a reminder, it brings things to the forefront of your mind.’’ ‘‘Mentors behaviour is a factor, after all they are teaching you. I remember thinking in my current placement everyone is washing their hands, it definitely has an impact. There is poor practice as well but you just rise above that.’’ At this point additional information was introduced to challenge the underpinnings of the students self-reports. Before 1995 the Centre for Disease Control and Prevention Guidelines on hand washing explicitly stated that hand cleansing was not necessary after all patient contacts, but merely after prolonged ones. This changed in 1995 because of the increasing incidence of antimicrobial resistant pathogens spread through hands (Elliott, 2003). However, applying this in acute settings could generate up to 40 Hand Hygiene episodes, per single patient, per hour (Gould, 2004). To attain full compliance staff may have to decontaminate their hands in excess of 100 times in a single shift (Vandenbrouke-Grauls, 2000). Boyce (2001) calculated that on a 12 bedded intensive care unit hand washing would require 16 h of nursing time per shift. Students were asked to consider these figures and hand hygiene in relation to all care episodes. Two further themes emerged real world compliance and flawed self assessment.
Real world compliance ‘‘I am shocked. I do not think those figures are very realistic. In today’s health care, time is precious; despite best intentions, there are so many other things to do. It is not just about time though, the state of someone’s hands, what would they be like?’’ ‘‘You cannot wash your hands that many times. You consciously or subconsciously develop a hierarchy and see some jobs as higher risk than others. You instinctively wash you hands after things like handling body fluids or treating someone who has MRSA, because people can
M. Cole see, feel and know the risk. But social care, I have never seen it and I have never done it.’’ Students were asked how they reconciled their shock of these figures and their reporting of excellent knowledge and excellent standards.
Unrealistic optimism ‘‘Although I was shocked, I probably shouldn’t be. I know what the guidelines say and I know what I should do. But guidelines are a gold standard, they are aspirational. We talk about evidence based practice but I think it is a human characteristic to pick and chose some of your evidence.’’ ‘‘It’s complicated; you always overestimate your ability and ignore your deficiencies. It’s a self image thing; hand washing is very big at the moment. You would have to be very brave to say you don’t do it, that would be a terrible loss of face; you just couldn’t say it.’’
Discussion In the quantitative phase of the study respondents reported a positive attitude and high self evaluation of their hand hygiene behaviour. Although no attempt was made to observe their behaviour this is consistent with the notions of high self assessment and over reporting that are well established in the literature (O’Boyle et al., 2001; Alexander and Sirotnak, 1997; Larson et al., 1997; Tibballs, 1996 Alvaran et al., 1994; Henry et al., 1994). When researchers correlate self assessment of knowledge and skill against objective performance, the relationship they find is rarely strong (Chemers et al., 2001; Stajkovic and Luchins, 1998; DePaulo et al., 1997). Jenner et al. (2006) suggests self reporting in relation to hand hygiene is so unreliable it should only be used with extreme caution. When additional cognitive information was introduced during the qualitative phase, respondents were surprised and then became more candid.
Unrealistic optimism Unrealistic optimism refers to the notion that people systematically overestimate the probability that good things will happen to them and underestimate the probability that bad things will happen (Weinstein, 1980). A recent review found that this phenomenon is extremely robust and not limited by demographics such as age, sex, education or occu-
Exploring the hand hygiene competence of student nurses: A case of flawed self assessment pation (Wenglert and Rosen, 2000).The reasons why people can be self serving in their judgements, leading to flawed self assessments can be explained by the fact that, firstly people are motivated to present a positive view of themselves and secondly they make systematic information processing errors when analyzing situations (Dunning, 2005).
Self-esteem Optimistic biases can derive from motivational causes such as a need to protect self, self-esteem and preventing anxiety (Boney-McCoy et al., 1999; Gerrard et al., 1996; Croyle et al., 1993). Self evaluation is not a cold cognitive process, involving objective compilation of information; rather, it is influenced by the motivations that lead people to evaluate themselves in the first place (Taylor and Nester, 1995). This influences the way in which people seek out, attend to, recall and attribute information about themselves (Gross, 2005). Good hand hygiene is commonly perceived as an important and fundamental nursing skill (Pratt et al., 2001) a simple task (Babacombe, 2004) and a measure that prevents morbidity and mortality in patients (Department of Health, 2003). If as some suggest, high occupational self-esteem is important (Randle, 2003) it may be problematic and damaging to the occupational self-esteem of health care staff to admit that they are poor hand washing compliers.
Information processing errors Cognitive explanations of unrealistic optimism are based on the assumptions that people make systematic information processing errors when analyzing situations (Dunning et al., 2004). Two important components are the above average effect the notion that people tend to believe that they are above average (Clarke et al., 2000) and the overconfidence effect that people place too much confidence in the insightfulness of their judgements (Oksam, 2000). None of the respondents in this study saw themselves as average and reported scores higher than those of their colleagues. All respondents reported a high knowledge of guidelines although no one had actually read them. It is posited in this study that although the behavioural educational strategies pre-eminent in hand hygiene education (Sax et al., 2007) make a significant contribution to the development of practice, they may exacerbate problems of objective self assessment, and as such, have a negative influence on practice. Within a taxonomy of learn-
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ing, strategies need to be introduced into the nursing curriculum that develop the cognitive process dimension and build on the student’s knowledge and skills in order to develop understanding and insight.
Future educational strategies The ability to accurately self assess ones competence and achievements is not a natural gift, but rather, a skill that can be learned, improved on and excelled in (Mattheos et al., 2004). Moreover, skills that engender competence are the same skills that are required to evaluate competency (Kruger, 1999). One of the aims of a nursing curriculum should be to ensure that students are competent not only in a clinical procedure like hand washing, but also in their ability to constructively assess themselves. There is a sense that self assessment is synonymous with reflection (Price, 2005) and nurses should use both as a continuous part of their professional work and learning (Ekebergh et al., 2004; Thorpe, 2004). Reflection requires the individual to be self aware and have an ability to analyze knowledge to develop newer and deeper perspectives (Halford and Leonard, 2003). Synthesis and evaluation of new ideas, concepts and/or mind sets may emerge resulting in altered ways of caring and maintaining performance (Simmonds, 2003). Self-assessment through reflection would allow the student to consider their practice within the clinical environment and gain insight into their performance in order to identify strengths and areas for further development (Campbell and Mackay, 2001; Hannigan, 2001). Reflective practice has a role to play at all stages of the ‘novice to expert’ continuum (Paget, 2001) and there are a number of techniques cited in the literature including critical incidents, supervision and reflective journals for doing this (Hargreaves, 2004). Journal writing is a technique that has long been advocated (Kessler, 2004; Williams et al., 2000; Boud et al., 1985) as it said to enhance self-awareness, interpersonal understanding, critical analysis, cognitive learning and clinical reasoning skills (Chirema, 2007). Although clearly time consuming, journal writing is a technique worthy of further consideration. In her study Larson et al. (2004) used diary cards as a strategy for nurses to self assess their hand hygiene behaviour and minimize the problem of recall bias. I believe this could be used more widely to support and enhance the established behavioural methods of teaching. A common theme to emerge in this study is that when asked, none of the respondents felt confident to estimate or quantify
386 their hand washing performance. More typically students would volunteer ‘‘I don’t know how many times, I couldn’t put a number on it, but I know it’s a lot’’. The availability heuristic posits that categorical judgements are easily influenced by how easily similar examples can be retrieved from the memory (Buckingham and Adams, 2000). As such students may find it easy to recall the times they washed their hands rather than the times they did not, and therefore exacerbate the problems of objective self assessment. Asking students to reflect upon their performance, and importantly record it, could be one method of facilitating greater insight and prove fertile grounds for discussion through critical analysis. Similarly this could be extended by asking students to consider different levels of compliance before and after different types of activities or different performance levels in relation to different shift patterns. This type of data is sadly lacking and this study suggests that students rarely consider the salience of these factors.
Conclusion The word competence is used extensively in nursing education and is gaining international recognition as a means of developing the clinical skills that are a critical component of any undergraduate nursing programme. Hand hygiene is considered a core skill, that can have an enormous impact on the morbidity and mortality associated with hospital acquired infection. Although presented as a simple, mechanical procedure, compliance associated with hand hygiene is in fact complex and incorporates knowledge and behaviours at many levels. While the term competence may include caveats that encourage educationalists to view it in a multi-faceted, holistic way, the pre-eminent model for hand hygiene training remains didactic, performance based and outcome driven. Though this model has been extremely successful at developing practice through the acquisition of knowledge and psychomotor skills, because of its perceived importance, staff feel compelled to report an unlikely level of compliance. Moreover, as self assessment is synonymous with over reporting it has been largely discredited within hand hygiene research. Nevertheless, it is plausible that flawed self assessments are not the result of dishonesty but the consequence of an inability to objectively self assess. Rather than rejecting the notion it is posited that self assessment is a fundamental component of hand hygiene competence. Learnt skills and
M. Cole motivation to improve will be mediated by how individuals see their current practice. Behavioural educational strategies have their place and are an important approach to teach underpinning principles, at an early stage in an undergraduate programme. However, a taxonomy should be developed that revisits the topic and challenges common assumptions about practice. Cognitive strategies that require students to reflect on their practice and objectively assess their own performance may better enable them to problem solve, seek out new information, draw on past experience and gain a greater and deeper understanding of complex compliance issues.
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