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Hand hygiene knowledge and practices of nursing students in Singapore
American Journal of Infection Control 40 (2012) e241-3
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Hand hygiene knowledge and practices of nursing students in Singapore A.M.A. Nasirudeen PhD *, Josephine W.N. Koh RN, MSocSc, BHSc, AdvDip(Ortho), Adeline Lee Chin Lau RN, BHSc, PGDip(HEd), Wenjie Li RN, BHSc, PGDip(HEd), Lay Seng Lim RN, BHSc, Cynthia Yi Xuan Ow RN, BHSc School of Health Sciences, Ngee Ann Polytechnic, Singapore
Key Words: Attitudes Compliance Handwashing Infection control Nursing education
Hand hygiene is an important means of preventing nosocomial infections. Studies have shown a <50% compliance rate for hand hygiene among health care workers. A hand hygiene survey was administered to nursing students in a tertiary institution in Singapore. The results of this survey strongly indicate that nursing students understand the importance of hand hygiene compliance and perceive clinical internship programs and practical laboratory sessions to be effective methods of hand hygiene education. Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Hand hygiene, or handwashing, is the single most important factor in preventing hospital-acquired infections.1 Effective hand hygiene compliance can lower the prevalence of health caree associated infections.2 Nursing care accounts for approximately 80% of the direct care of patients, involving personal and intimate care activities.3 Nursing students are in contact with patients during clinical practicum and internship programs as part of their educational course requirements. In the present study, we aimed to identify hand hygiene knowledge, self-reported compliance, effective teaching and assessment methods, and attitudes toward interventions promoting hand hygiene compliance among graduating nursing students. To the best of our knowledge, this is the first study of nursing students’ hand hygiene knowledge and practices in a tertiary institution in Singapore. METHODS A total of 431 nursing students studying in a tertiary institution in Singapore completed a self-administered, anonymous survey. The survey questions were designed based on current themes in hand hygiene identified in the literature. The survey respondents were final-year nursing students in the Diploma of Health Sciences (Nursing) program at an institution of
higher learning in Singapore. These students were chosen for the following reasons: (1) Most of their hand hygiene education had been completed; (2) they have completed at least 2 clinical attachments or practicums in their 3 years of nursing education (to examine hand hygiene practice in the clinical environment); and (3) because final-year students will begin working as full-time nurses soon, the survey would act as an intervention aimed at increasing hand hygiene compliance in these new nurses. Limitations of the study include the predominately female study population (83.1%), the reliance on self-reported data, and the restriction to only finalyear nursing students. Written permission to conduct the research was obtained from the institution’s Research and Ethics Committee. Written consent was obtained from each participant before administering the survey. The confidentiality of information gathered on the survey forms was guaranteed. Each respondents was informed that his or her participation in the study was voluntary. Data from the survey were transferred to Microsoft Excel 2010 (Microsoft, Redmond, WA). Standard data entry and quality control procedures were used, including double entry, range and consistency checks, and manual review of outliers. All statistical analyses were performed using SPSS version 19.0 (IBM, Armonk, NY). RESULTS
* Address correspondence to A.M.A. Nasirudeen, PhD, Ngee Ann Polytechnic School of Health Sciences, Block 81, #06-00, 535 Clementi Road, Singapore 599489, Singapore. E-mail address: [email protected] (A.M.A. Nasirudeen). Conflict of interest: None to report.
The nursing students who participated in this survey had done their clinical attachments in at least 2 different departments in a hospital in Singapore. More than 90% of the students had done clinical attachments in medical and pediatrics departments, and
0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2012.02.026
e242
A.M.A. Nasirudeen et al. / American Journal of Infection Control 40 (2012) e241-3
Table 1 Interventions and their perceived effect on hand hygiene compliance Intervention Easy access to sinks Hand hygiene feedback by authority Better soaps and lotions Rewards for hand hygiene compliance Infection control information sessions/talks Visual aids or prompts Punishment for lack of compliance Hand hygiene feedback by peers Decrease in workload
Increase compliance, n (%) 372 351 349 349 347 316 313 274 249
Decrease compliance, n (%)
(86.3) (81.4) (81) (81) (80.5) (73.3) (72.6) (63.6) (57.8)
more than 75% of them had been attached to surgery and obstetrics departments in hospitals as well. To determine whether the number of departments to which a student was attached affected hand hygiene compliance, we compared the mean compliance in students with clinical attachments in 1 department, 2 departments, or 3 or more departments. Mean compliance was similar regardless of the number of departments to which a student was attached. On the survey, 286 of the respondents (66.3%) self-reported hand hygiene compliance of 90%. The survey included a short hand hygiene quiz comprising multiple-choice questions. One hundred and eighty-five respondents (48.9%) answered all the questions correctly. Four hundred and eleven respondents (95.3%) correctly answered 60% or more of the questions on hand hygiene knowledge. The average score for the quiz was 75%. To evaluate whether knowledge of hand hygiene influenced compliance, we used a paired-samples test to compare hand hygiene compliance in the students who answered 60% or more of the quiz questions correctly. The results were statistically significant (P < .001), suggesting that knowledge of hand hygiene influences compliance. More than 80% of respondents reported that easy access to sinks, hand hygiene feedback by authorities, better soaps and lotions, rewards for hand hygiene compliance, and infection control
32 34 29 13 29 28 73 53 70
(7.4) (7.9) (6.7) (3) (6.7) (6.5) (16.9) (12.3) (16.2)
No effect on compliance, n (%) 27 46 53 69 55 87 45 104 112
(6.3) (10.7) (12.3) (16) (12.8) (20.2) (10.4) (24.1) (26)
information sessions or talks would lead to increased hand hygiene compliance (Table 1). Two hundred forty-nine respondents (57.8%) reported that a decrease in workload would lead to increased hand hygiene compliance. On a separate question in which respondents were asked to consider the effectiveness of various hand hygiene improvement strategies, 95.4% reported that reinforcement of the importance of hand hygiene practice by mentors would significantly influence their own compliance rates. When asked to rate the effectiveness of hand hygiene teaching methods, the respondents rated clinical internship programs (74.9%) and practical laboratory sessions (66.6%) as significantly more effective than other methods of hand hygiene education. Lectures were deemed the least effective mode of hand hygiene education (Fig 1). DISCUSSION Previous studies have linked increased compliance with hand hygiene to significantly reduced infection rates.4,5 Educating nursing students on effective hand hygiene techniques and compliance is highly important, because these students are the future health care workforce.6 Our survey findings show that nursing students in Singapore have good hand hygiene knowledge, receive various types of hand
Fig 1. Effective methods of hand hygiene education. Note that clinical internship program and practical laboratory sessions were rated as highly effective methods of hand hygiene education.
A.M.A. Nasirudeen et al. / American Journal of Infection Control 40 (2012) e241-3
hygiene education, and are frequently assessed using different methods. In agreement with results reported by Snow et al,7 our findings also show that nursing students perceive that their mentors’ hand hygiene practices positively influence their own hand hygiene compliance. Another study found that nursing students followed the hand hygiene practice of their mentors to maintain a good working relationship.6 Our results also show that easy access to sinks is the most effective intervention in increasing hand hygiene compliance, in agreement with the results of Harris et al.8 However, contrary to Harris et al, we found that rewards for hand hygiene compliance and punishment for lack of compliance have significant effects on increasing hand hygiene compliance. Our results demonstrate the vital importance of academic instructors and nursing clinical instructors in keeping students’ knowledge of hand hygiene up to date during practical laboratory sessions and clinical internship programs and in acting as mentors and providing constructive feedback to students to improve their hand hygiene compliance.
e243
References 1. Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics 2004; 114:e565-71. 2. Sahay S, Panja S, Ray S, Rao BK. Diurnal variation in hand hygiene compliance in a tertiary-level multidisciplinary intensive care unit. Am J Infect Control 2010; 38:535-9. 3. Wade S. Partnership in care: a critical review. Nursing Std 1995;9:29-32. 4. Leclair JM, Freeman J, Sullivan BF, Crowley CM, Goldmann DA. Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions. N Engl J Med 1987;317:329-34. 5. Conly JM, Hill S, Ross J, Lertzman J, Louie TJ. Handwashing practices in an intensive care unit: the effects of an educational program and its relationship to infection rates. Am J Infect Control 1989;17:330-9. 6. Barrett R, Randle J. Hand hygiene practices: nursing students’ perceptions. J Clin Nurs 2008;17:1851-7. 7. Snow M, White GL Jr, Alder SC, Stanford JB. Mentors’ hand hygiene practices influence students’ hand hygiene rates. Am J Infect Control 2006;34: 18-24. 8. Harris AD, Samore MH, Nafziger R, DiRosario K, Roghmann MC, Carmeli Y. A survey on handwashing practices and opinions of healthcare workers. J Hosp Infect 2000;45:318-21.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Brief report
Hand hygiene knowledge and practices of nursing students in Singapore A.M.A. Nasirudeen PhD *, Josephine W.N. Koh RN, MSocSc, BHSc, AdvDip(Ortho), Adeline Lee Chin Lau RN, BHSc, PGDip(HEd), Wenjie Li RN, BHSc, PGDip(HEd), Lay Seng Lim RN, BHSc, Cynthia Yi Xuan Ow RN, BHSc School of Health Sciences, Ngee Ann Polytechnic, Singapore
Key Words: Attitudes Compliance Handwashing Infection control Nursing education
Hand hygiene is an important means of preventing nosocomial infections. Studies have shown a <50% compliance rate for hand hygiene among health care workers. A hand hygiene survey was administered to nursing students in a tertiary institution in Singapore. The results of this survey strongly indicate that nursing students understand the importance of hand hygiene compliance and perceive clinical internship programs and practical laboratory sessions to be effective methods of hand hygiene education. Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Hand hygiene, or handwashing, is the single most important factor in preventing hospital-acquired infections.1 Effective hand hygiene compliance can lower the prevalence of health caree associated infections.2 Nursing care accounts for approximately 80% of the direct care of patients, involving personal and intimate care activities.3 Nursing students are in contact with patients during clinical practicum and internship programs as part of their educational course requirements. In the present study, we aimed to identify hand hygiene knowledge, self-reported compliance, effective teaching and assessment methods, and attitudes toward interventions promoting hand hygiene compliance among graduating nursing students. To the best of our knowledge, this is the first study of nursing students’ hand hygiene knowledge and practices in a tertiary institution in Singapore. METHODS A total of 431 nursing students studying in a tertiary institution in Singapore completed a self-administered, anonymous survey. The survey questions were designed based on current themes in hand hygiene identified in the literature. The survey respondents were final-year nursing students in the Diploma of Health Sciences (Nursing) program at an institution of
higher learning in Singapore. These students were chosen for the following reasons: (1) Most of their hand hygiene education had been completed; (2) they have completed at least 2 clinical attachments or practicums in their 3 years of nursing education (to examine hand hygiene practice in the clinical environment); and (3) because final-year students will begin working as full-time nurses soon, the survey would act as an intervention aimed at increasing hand hygiene compliance in these new nurses. Limitations of the study include the predominately female study population (83.1%), the reliance on self-reported data, and the restriction to only finalyear nursing students. Written permission to conduct the research was obtained from the institution’s Research and Ethics Committee. Written consent was obtained from each participant before administering the survey. The confidentiality of information gathered on the survey forms was guaranteed. Each respondents was informed that his or her participation in the study was voluntary. Data from the survey were transferred to Microsoft Excel 2010 (Microsoft, Redmond, WA). Standard data entry and quality control procedures were used, including double entry, range and consistency checks, and manual review of outliers. All statistical analyses were performed using SPSS version 19.0 (IBM, Armonk, NY). RESULTS
* Address correspondence to A.M.A. Nasirudeen, PhD, Ngee Ann Polytechnic School of Health Sciences, Block 81, #06-00, 535 Clementi Road, Singapore 599489, Singapore. E-mail address: [email protected] (A.M.A. Nasirudeen). Conflict of interest: None to report.
The nursing students who participated in this survey had done their clinical attachments in at least 2 different departments in a hospital in Singapore. More than 90% of the students had done clinical attachments in medical and pediatrics departments, and
0196-6553/$36.00 - Copyright Ó 2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.ajic.2012.02.026
e242
A.M.A. Nasirudeen et al. / American Journal of Infection Control 40 (2012) e241-3
Table 1 Interventions and their perceived effect on hand hygiene compliance Intervention Easy access to sinks Hand hygiene feedback by authority Better soaps and lotions Rewards for hand hygiene compliance Infection control information sessions/talks Visual aids or prompts Punishment for lack of compliance Hand hygiene feedback by peers Decrease in workload
Increase compliance, n (%) 372 351 349 349 347 316 313 274 249
Decrease compliance, n (%)
(86.3) (81.4) (81) (81) (80.5) (73.3) (72.6) (63.6) (57.8)
more than 75% of them had been attached to surgery and obstetrics departments in hospitals as well. To determine whether the number of departments to which a student was attached affected hand hygiene compliance, we compared the mean compliance in students with clinical attachments in 1 department, 2 departments, or 3 or more departments. Mean compliance was similar regardless of the number of departments to which a student was attached. On the survey, 286 of the respondents (66.3%) self-reported hand hygiene compliance of 90%. The survey included a short hand hygiene quiz comprising multiple-choice questions. One hundred and eighty-five respondents (48.9%) answered all the questions correctly. Four hundred and eleven respondents (95.3%) correctly answered 60% or more of the questions on hand hygiene knowledge. The average score for the quiz was 75%. To evaluate whether knowledge of hand hygiene influenced compliance, we used a paired-samples test to compare hand hygiene compliance in the students who answered 60% or more of the quiz questions correctly. The results were statistically significant (P < .001), suggesting that knowledge of hand hygiene influences compliance. More than 80% of respondents reported that easy access to sinks, hand hygiene feedback by authorities, better soaps and lotions, rewards for hand hygiene compliance, and infection control
32 34 29 13 29 28 73 53 70
(7.4) (7.9) (6.7) (3) (6.7) (6.5) (16.9) (12.3) (16.2)
No effect on compliance, n (%) 27 46 53 69 55 87 45 104 112
(6.3) (10.7) (12.3) (16) (12.8) (20.2) (10.4) (24.1) (26)
information sessions or talks would lead to increased hand hygiene compliance (Table 1). Two hundred forty-nine respondents (57.8%) reported that a decrease in workload would lead to increased hand hygiene compliance. On a separate question in which respondents were asked to consider the effectiveness of various hand hygiene improvement strategies, 95.4% reported that reinforcement of the importance of hand hygiene practice by mentors would significantly influence their own compliance rates. When asked to rate the effectiveness of hand hygiene teaching methods, the respondents rated clinical internship programs (74.9%) and practical laboratory sessions (66.6%) as significantly more effective than other methods of hand hygiene education. Lectures were deemed the least effective mode of hand hygiene education (Fig 1). DISCUSSION Previous studies have linked increased compliance with hand hygiene to significantly reduced infection rates.4,5 Educating nursing students on effective hand hygiene techniques and compliance is highly important, because these students are the future health care workforce.6 Our survey findings show that nursing students in Singapore have good hand hygiene knowledge, receive various types of hand
Fig 1. Effective methods of hand hygiene education. Note that clinical internship program and practical laboratory sessions were rated as highly effective methods of hand hygiene education.
A.M.A. Nasirudeen et al. / American Journal of Infection Control 40 (2012) e241-3
hygiene education, and are frequently assessed using different methods. In agreement with results reported by Snow et al,7 our findings also show that nursing students perceive that their mentors’ hand hygiene practices positively influence their own hand hygiene compliance. Another study found that nursing students followed the hand hygiene practice of their mentors to maintain a good working relationship.6 Our results also show that easy access to sinks is the most effective intervention in increasing hand hygiene compliance, in agreement with the results of Harris et al.8 However, contrary to Harris et al, we found that rewards for hand hygiene compliance and punishment for lack of compliance have significant effects on increasing hand hygiene compliance. Our results demonstrate the vital importance of academic instructors and nursing clinical instructors in keeping students’ knowledge of hand hygiene up to date during practical laboratory sessions and clinical internship programs and in acting as mentors and providing constructive feedback to students to improve their hand hygiene compliance.
e243
References 1. Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics 2004; 114:e565-71. 2. Sahay S, Panja S, Ray S, Rao BK. Diurnal variation in hand hygiene compliance in a tertiary-level multidisciplinary intensive care unit. Am J Infect Control 2010; 38:535-9. 3. Wade S. Partnership in care: a critical review. Nursing Std 1995;9:29-32. 4. Leclair JM, Freeman J, Sullivan BF, Crowley CM, Goldmann DA. Prevention of nosocomial respiratory syncytial virus infections through compliance with glove and gown isolation precautions. N Engl J Med 1987;317:329-34. 5. Conly JM, Hill S, Ross J, Lertzman J, Louie TJ. Handwashing practices in an intensive care unit: the effects of an educational program and its relationship to infection rates. Am J Infect Control 1989;17:330-9. 6. Barrett R, Randle J. Hand hygiene practices: nursing students’ perceptions. J Clin Nurs 2008;17:1851-7. 7. Snow M, White GL Jr, Alder SC, Stanford JB. Mentors’ hand hygiene practices influence students’ hand hygiene rates. Am J Infect Control 2006;34: 18-24. 8. Harris AD, Samore MH, Nafziger R, DiRosario K, Roghmann MC, Carmeli Y. A survey on handwashing practices and opinions of healthcare workers. J Hosp Infect 2000;45:318-21.