- Email: [email protected]
Parent willingness to remind health care workers to perform hand hygiene
American Journal of Infection Control 41 (2013) 492-6
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Parent willingness to remind health care workers to perform hand hygiene Genevieve L. Buser MDCM, MSHP a, *, Brian T. Fisher DO, MSCE a, Judy A. Shea PhD b, Susan E. Coffin MD, MPH a a b
Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA
Key Words: Health care-associated infections Patient safety Pediatric Family-centered care Positive deviance
Background: Health care worker (HCW) hand hygiene (HH) is the core strategy to prevent health careassociated infections (HAI). Suboptimal HCW HH rates continue despite hospital efforts to increase compliance. Objectives: To determine whether parents of hospitalized children perceive they have a role in preventing HAI and whether they are willing to remind HCW to perform HH, with and without an invitation. Methods: We conducted structured interviews of parents of children admitted to a pediatric hospital. Questions assessed knowledge, attitudes, and behaviors about HAI and HH. The primary outcome was willingness to remind a HCW to do HH (5-point Likert scale). Results: We interviewed 115 parents, of whom 84% were aware of HAI. Most parents (78%) perceived HH as the most important practice to prevent HAI. However, only 67% would definitely remind a HCW to perform HH. Importantly, 92% said that an invitation from a HCW would make them more likely to remind a HCW to do HH in the future. Conclusion: Our results suggest that parents of hospitalized children are willing to help prevent HAI; however one-third are still reluctant to remind HCW to perform HH. An invitation by HCW to parents to remind HCW to perform HH might effectively engage parents as partners in HAI prevention. Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc.
Proper hand hygiene (HH) is the cornerstone of multiple evidence-based strategies to prevent health care-associated infections (HAI).1-3 High levels of adherence to HH by health care workers (HCW) are difficult to sustain because HH requires a change in behavior, requires frequent repetition, and competes with other tasks for time and attention.4,5 One strategy to increase HH is through direct observation and real-time feedback.6-8 Patient participation is a mechanism to provide direct observation and feedback to HCW about HH.1,3,9,10 However, studies to assess patient reminders to HCW to perform HH have demonstrated a gap between willingness and action.11-13 Among adult inpatients, 70% reported being worried about the risk of HAI; however, only 41% of respondents thought that a patient should remind HCW to cleanse their hands.11 Even fewer (22%) said they would be comfortable reminding a nurse or physician to perform HH. Inaction may be related to professional status (ie, questioning
* Address correspondence to Genevieve L. Buser, MDCM, MSHP, Oregon Public Health Division, 800 NE Oregon Street, Portland, OR 97232. E-mail address: [email protected] (G.L. Buser). Conflicts of interest: None to report.
authority) and seniority (ie, less likely to remind a physician compared with a nurse).11,14-16 Thus, knowledge alone is insufficient to ensure patient participation in HAI prevention. Although patient participation in health care behaviors begins with knowledge (ie, HAI prevention by HH), an opportunity and decision to intervene are required to lead to the desired behavior (ie, reminding a HCW to perform HH).1,17,18 Encouraging patient self-efficacy may diminish the barrier between intention and action.1,3,12,17 An invitation to remind HCW has been proposed as a mechanism to empower patient intervention by diminishing perceived barriers and modeling desired outcome (eg, positive deviance).8,11,14,19 For example, an invitation by a HCW to an adult patient to remind the HCW to wash their hands more than doubled the patients’ intention to intervene (30% to 78% for physician HCW).11 We wanted to assess how parents might be engaged by invitation to increase HCW HH in a pediatric health care setting. Such an invitation from HCW to parents to collaborate in HAI prevention is consistent with family-centered care, a cornerstone of pediatric health care delivery.20-22 We performed a study to describe parental knowledge, beliefs, and intentions toward HCW HH and to further investigate whether parent participation in HAI prevention is acceptable to parents. In
0196-6553/$00.00 - Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. http://dx.doi.org/10.1016/j.ajic.2012.08.006
G.L. Buser et al. / American Journal of Infection Control 41 (2013) 492-6
addition, the study was designed to assess whether an invitation from a HCW would increase the likelihood that the parent would remind the HCW to perform HH. METHODS Study design and population We conducted a cross-sectional, structured interview of parents of hospitalized children at the Children’s Hospital of Philadelphia, an academic, quaternary children’s hospital with 460 beds in Philadelphia, PA. The study protocol was approved by the Institutional Review Board. Study subjects A pool of potential participants was identified by a review of daily admission logs between October 26, 2010, and December 18, 2010. Potential participants were selected from among new admissions to nonintensive care units using a random number generator. Parents or guardians were eligible for participation if they (1) spoke English and (2) their child had been admitted less than 48 hours prior to survey administration. Structured interview Eligible parents were approached at the bedside, invited to participate, and verbally consented to be interviewed. The questionnaire was adapted from a study specific to adult inpatients. The adapted version contained 40 questions, in multiple-choice, 5-point-Likert-scale or short-answer formats.11 The adapted questionnaire was piloted on 10 families and revised accordingly. Interviews were performed using a visual aide to assist with comprehension. Interview topics included the following: (1) parent and child characteristics, including past hospitalizations and chronic medical conditions; (2) parent knowledge about HAI prevention; (3) evaluation of the parent’s intention to intervene to remind HCW to perform HH (Likert scale); and (4) motivators or barriers to parent intervention (open-ended). Age, history of past hospitalization, history of chronic medical condition, and history of HAI were collected for both the parent and the child. Data on relation to the patient, race, ethnicity, education, and health care employment were collected about parents. Specific patient risk factors for HAI were collected for the child. Definitions A chronic medical condition was defined as an illness lasting 3 months that impacts the patient’s normal activities and requires frequent treatment. A risk factor for HAI was defined as an indwelling medical device (eg, endotracheal tube, central venous catheter, and urinary catheter), surgical incision, implant, or organ transplant during the current admission. Health care facility employment was defined as having worked or volunteered in a clinic or hospital. Knowledge of correct HH technique was defined as washing with soap and water for a minimum of 15 seconds. Intention to intervene was assessed by a hypothetical situation: “If you saw that the doctor or nurse had not washed their hands prior to examining, taking vital signs, or giving medication to your child, how likely would you remind them to wash their hands?” Likert scale choices used the following format: “definitely not likely,” “unlikely,” “neither,” “somewhat likely,” “definitely likely.” This was followed by an explicit invitation: “If a doctor or nurse said to you, ‘Please remind me to wash my hands’ when they introduced
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themselves, would you be more or less likely to remind them in the future?” After reviewing the distribution of scale responses, the following groupings were used: a response of 1 or 2 was coded as negative; a response of 3 was coded as neutral; a response of 4 or 5 was coded as affirmative. Open responses were grouped into common themes and reported as frequencies. Statistical analysis Descriptive analysis Categorical variables are presented as frequencies, and continuous variables are summarized by mean or medians when appropriate. Ordinal variables (eg, Likert 5-point scales) were expressed using frequencies, medians, and percentages. Cronbach a was <.8 for the main domains of the survey. Comparative analysis This study had 2 distinct comparative outcomes. The first was to compare parents’ willingness to remind a HCW to perform HH before and after an invitation. The second was to compare parents reporting a definite intention to remind HCW tp those without a definite intention. For comparative analyses, 5-point Likert scale responses were dichotomized. Univariate comparison of categorical variables was performed using the Pearson c2 or Fisher exact test (if frequency of events 5). Comparison of continuous variables was executed using the Student t test. The explanatory variables significantly associated with the outcome of interest and those with a plausible correlation to the outcome a priori were included in stepwise fashion to a multivariate logistic regression model. All analyses used 2-tailed tests and 95% confidence intervals; P values <.05 were considered significant. Sample size and power Based on previous research, we estimated that 30% of parents would remind the HCW to perform HH at baseline, and an additional 30% would do so after an invitation.11 Assuming each subject’s responses represented a matched pair (before and after an invitation), a sample size of 115 subjects would achieve 80% power to detect an odds ratio of 3, if the true difference before and after the intervention was at least 20%, using a 2-sided McNemar test with a significance level of .05. Statistical analysis was performed using Stata Version 11 (StatCorp LP, College Station, TX). RESULTS Four hundred six potential participants were selected from admission lists; 115 (28%) parents were consented and interviewed. Nonparticipation occurred for the following reasons: parent was unavailable, or patient was discharged (230/406, 57%); inconvenient time (31, 8%); parent specifically declined to be interviewed (20, 5%); non-English speaking parent (10, 3%). Nonparticipants did not differ significantly from participants in terms of patient’s age, gender, uninsured status, or general versus specialty unit status. Characteristics of interviewed parents The characteristics of interviewed parents and children are summarized in Table 1. Most parents were mothers (92/115, 80%), white (57%), non-Hispanic (87%), and between 35 and 44 years of age (35%; range, <18 to >60 years). More than two-thirds (77%) completed at least some college or trade school. A substantial proportion of parents (43%) had ever worked or volunteered in a health care facility. Five parents (4%) reported an HAI in the past.
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G.L. Buser et al. / American Journal of Infection Control 41 (2013) 492-6
Table 1 Selected parent and child characteristics, N ¼ 115 Characteristic Age Race, n (%)
Highest education level, n (%)
Chronic medical condition, n (%) Hospital experience, n (%)
HAI risk factor during admission, n (%)
Previous HAI
Median (range) White Black Other Hispanic Less than high school High school diploma/GED Some college/trade/AA 4-year college degree or greater Yes Hospitalized previously, ever Hospitalized >7 times Hospitalized >5 days
Parents
Children
35-44 years (18-60þ years) 66 (57) 34 (30) 15 (13) 15 (13) 4 (4) 23 (20) 44 (38) 44 (38) 30 (26) 80 (70) 8 (7) 30 (26)
6 years (1 mo to 18 years) –
1 Risk factor 2 Risk factors 3 Risk factors Yes
–
5 (4)
– –
69 81 21 47
(60) (70) (18) (40)
40 22 12 13
(35) (19) (10) (11)
AA, Associates degree; GED, general equivalency diploma; HAI, health care-associated infection.
Characteristics of children Children were aged 1 month to 18 years (right-tailed: median, 6.0 years; interquartile range, 1.2-11 years). More than half (60%) had chronic medical conditions, the most common being asthma (22/69, 32%), gastrointestinal disorder (18, 26%), immunocompromised condition (14, 20%), and neurologic syndrome (8, 12%). More than one-third of the children (35%) had 1 risk factor for HAI present during this hospitalization, and 19% had 2 risk factors for HAI. Thirteen children (11%) reported 17 episodes of HAI. Parental knowledge, perceptions, and intentions toward preventing HAI Parental knowledge, perceptions, and intentions toward preventing HAI are summarized in Table 2. More than two-thirds of parents (71%) believed they play an important role in preventing HAI in general. The majority of parents correctly identified HH as the most important intervention to prevent HAI (78%). However, less than half (44%) described proper hand hygiene. Parents reported that they received information about the hospital’s HH campaign by poster (68%), Web site (20%), HCW (14%), television (14%), or brochure (12%). The majority of parents reported being definitely willing to help improve HH in HCW (75%), but fewer would definitely act to remind a HCW to wash their hands (67%). However, 78% reported that they would definitely be more likely to remind a HCW to do HH after an invitation. After adjusting for age, education, history of chronic medical condition, prior hospitalizations, and experience working in health care, parent willingness to help prevent HAIs (adjusted odds ratio [aOR], 5.78; 95% confidence interval [CI]: 2.2-15.16; P < .0001) and belief that they had an important role in improving HH in HCW (aOR, 4.76; 95% CI: 1.64-13.77; P ¼ .004) were independently associated with a parent’s definite intention to remind a HCW to wash their hands.
Table 2 Knowledge, perception and intentions of parents of hospitalized children, N ¼ 115 Knowledge Aware of HAI prior to interview Identified importance of HH to prevent HAI Reported correct handwashing technique* Perceptions HAI would be a serious risk to child’s health Parents have an important role in preventing HAI Parents have an important role in improving HH in HCW Intentions Definitely willing to help improve HH in HCW Definitely likely to remind a HCW to perform HH Given an explicit invitation, definitely more likely to remind a HCW to do HH Actions Have previously reminded a HCW to wash their hands
n (%) 96 (84) 90 (78) 50 (44) 90 (78) 82 (71) 59 (51) 86 (75) 77 (67) 90 (78)
24 (21)
HAI, hospital-associated infection; HCW, health care worker; HH, hand hygiene. *Washing with soap and water for a minimum of 15 seconds.
to have worked in a health care facility (aOR, 4.39; 95% CI: 1.5912.16; P ¼ .004). Motivators and barriers Motivators and barriers to reminding HCW to perform HH were grouped by themes. Of those who reported barriers, the most common was a concern for “appearing rude or undermining authority” (11, 10%), followed by “assuming the HCW should know” (9, 8%), and an “intimidating manner by the HCW” (9, 8%). Parents also suggested motivating factors: “HCW gives an invitation or introduces topic” (17, 15%); “HCW is approachable and friendly” (13, 11%); parent witnesses an “unsanitary act or high-risk situation” (12, 10%); and there is “signage to remind parents to do HH” (5, 4%). Three parents (3%) interpreted the reminder as a lack of professionalism.
Parental actions toward improving HH
DISCUSSION
Twenty-four parents (21%) reported reminding a HCW to wash their hands in the past. On multivariate analysis adjusted for age, education, chronic medical condition, and prior hospitalizations, parents who had reminded HCW to perform HH were more likely
In this study, we found that parents were willing to help improve HH in HCWs. An explicit invitation was associated with increased willingness by parents to remind HCW to perform HH. Parents who believed they have a role to improve HH in HCW
G.L. Buser et al. / American Journal of Infection Control 41 (2013) 492-6
were more likely to have reminded a HCW to perform HH in the past. These findings build on existing literature about encouraging parent self-efficacy and promoting family-centered care, in which parents are invited to partner with their child’s medical team.20-23 Parents in this study were more likely to believe that they had a role in preventing HAIs and were more willing to remind HCW to wash their hands than adult patients in other studies.11,13,16 Also, 20% of parents reported having reminded a HCW in the past to perform HH, as compared with <10% of adult patients.11,13 A person’s decision to intervene in a positive health behavior is most influenced by outcome expectancies (ie, an action will result in a beneficial outcome) and self-efficacy (ie, the ability to influence one’s situation).18 We hypothesize that parents might be more likely to intervene because of their role as protector and advocate for their child, which might translate into higher outcome expectancies and self-efficacy. Thus, parents might be willing partners to engage to help prevent HAIs in the hospital.7 An invitation from a HCW was associated with an increase in the willingness of parents to remind a HCW to perform HH in the future. This is congruent with studies suggesting that reminders to HCW by patients might decrease social barriers caused by HCW professional status and seniority.3,14,15 McGuckin et al found that patient-initiated questioning of staff “Did you wash your hands?” increased HH long-term by 40% in an adult acute care hospital ward.24 An invitation from a HCW might diminish any perceived barriers to intervention and might encourage patient or parent participation. Parent participation in HAI prevention corresponds to principles of family-centered care by encouraging self-reliance in families and ensuring patient safety with continual HAI quality improvement by the health care team.20-23 Fundamental to any HAI improvement is an environment of safety where “the consideration of hand hygiene improvement [is] a high priority at all levels.”3 Parents are a part of the environment of safety: they are present at their child’s bedside and motivated to positively participate in their child’s hospital care. Parents can be taught basic preventative measures to prevent HAI (eg, 5 Moments of HH, central line care, and others).9,10,16,25 For example, applying the theories of “positive deviance,” HCW can model correct HH technique to parents and invite them to participate in HAI prevention practices, while reinforcing evidence-based practices by normalizing HH observation and feedback.8,19 Despite the potential benefits, a small number of parents had a negative response to the hypothetical intervention in this study. Some critics have expressed concerns about involving parents in HAI prevention.26 For example, parent involvement could make additional demands on HCW because parent education requires extra time by staff. Furthermore, parents and staff may perceive this oversight as policing rather than collaborating with HCW. However, these are theoretical barriers to parent involvement that could be addressed by proper implementation strategies (ie, close collaboration with family advocacy groups).3 Limitations We were unable to make robust statistical conclusions on the effect of an invitation to remind HCW to perform HH because we found a higher than expected positive parent involvement at baseline. Given the unexpected high positive response by parents to remind HCW to wash their hands prior to an invitation, the power to detect a difference before and after an invitation was only 0.463. However, this is an encouraging finding: the majority of parents is motivated to intervene on their child’s behalf to
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encourage HH in HCW. Our findings might not be generalized because the study occurred at a single center, and nonparticipants may have been different than participants by an untested parameter. Third, there is a potential framing bias: asking about HAIs implies importance, which might have influenced parents to overestimate their intentions. Conclusion Our results suggest that parents are willing and motivated to partner with HCW to prevent HAI in their children. A parentHCW HAI collaboration could improve child health by empowering parents to participate in HAI prevention efforts and remind HCW to wash their hands. In addition, HCW can promote parent partnerships by inviting participation and teaching correct HH technique. Together, willing parents and HCW could promote a culture of change to achieve improved HH compliance and prevent HAI. Acknowledgments We thank Brian Smith, Children's Hospital of Philadelphia; Judith Long, MD, University of Pennsylvania.
References 1. Pittet D, Allegranzi B, Boyce J. The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations. Infect Control Hosp Epidemiol 2009;30:611-22. 2. Yokoe DS, Mermel LA, Anderson DJ, Arias KM, Burstin H, Calfee DP, et al. A compendium of strategies to prevent health care-associated infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(Suppl 1):S12-21. 3. McGuckin M, Storr J, Longtin Y, Allegranzi B, Pittet D. Patient empowerment and multimodal hand hygiene promotion: a win-winstrategy. Am J Med Qual 2011;26:10-7. 4. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000;21:381-6. 5. Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004;141:1-8. 6. Shannon RP, Frndak D, Grunden N, Lloyd JC, Herbert C, Patel B, et al. Using realtime problem solving to eliminate central line infections. Jt Comm J Qual Patient Saf 2006;32:479-87. 7. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356:1307-12. 8. Marra Alexandre R, Reis Guastelli L, Pereira de Arajo Carla M, Saraiva dos Santos Jorge L, Lamblet Luiz Carlos R, Silva M Jr, et al. Positive deviance: a new strategy for improving hand hygiene compliance. Infect Control Hosp Epidemiol 2010;31:12-20. 9. Chen YC, Chiang LC. Effectiveness of hand-washing teaching programs for families of children in paediatric intensive care units. J Clin Nurs 2007;16:1173-9. 10. Reynolds L, Liverman T, Jacobs D, Bearman G, Edmond M. A creative yet simple approach to improve hand hygiene compliance in the pediatric intensive care unit. Am J Infect Control 2005;33:e156-7. 11. Longtin Y, Sax H, Allegranzi B, Hugonnet S, Pittet D. Patients’ beliefs and perceptions of their participation to increase healthcare worker compliance with hand hygiene. Infect Control Hosp Epidemiol 2009;30:830-9. 12. McGuckin M. Improving handwashing in hospitals: a patient education and empowerment program. LDI Issue Brief 2001;7:1-4. 13. Waterman AD, Gallagher TH, Garbutt J, Waterman BM, Fraser V, Burroughs TE. Brief report: hospitalized patients’ attitudes about and participation in error prevention. J Gen Intern Med 2006;21:367-70. 14. Gordon SC. A piece of my mind: ask me if I cleaned my hands. JAMA 2012;307: 1591-2. 15. Reid N, Moghaddas J, Loftus M, Stuart RL, Kotsanas D, Scott C, et al. Can we expect patients to question health care workers’ hand hygiene compliance? Infect Control Hosp Epidemiol 2012;33:531-2. 16. Davis RE, Koutantji M, Vincent CA. How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study. Qual Saf Health Care 2008;17:90-6. 17. Schwarzer R. Self-efficacy in the adoption and maintenance of health behaviors: theoretical approaches and a new model. In: Schwarzer R, editor. Selfefficacy: thought control of action. Washington [DC]: Hemisphere Publishing Corporation; 1992. p. 217-43.
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18. Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977;84:191-215. 19. Bradley EH, Curry LA, Ramanadhan S, Rowe L, Nembhard IM, Krumholz HM. Research in action: using positive deviance to improve quality of health care. Implement Sci 2009;4:25. 20. Rosen P, Stenger E, Bochkoris M, Hannon MJ, Kwoh CK. Family-centered multidisciplinary rounds enhance the team approach in pediatrics. Pediatrics 2009;123:e603-8. 21. Muething SE, Kotagal UR, Schoettker PJ, del Rey JG, DeWitt TG. Family-centered bedside rounds: a new approach to patient care and teaching. Pediatrics 2007; 119:829-32. 22. Coulter A. After Bristol: putting patients at the centre. Qual Saf Health Care 2002;11:186-8.
23. Aronson PL, Yau J, Helfaer MA, Morrison W. Impact of family presence during pediatric intensive care unit rounds on the family and medical team. Pediatrics 2009;124:1119-25. 24. McGuckin M, Taylor A, Martin V, Porten L, Salcido R. Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit. Am J Infect Control 2004;32: 235-8. 25. Moller T, Borregaard N, Tvede M, Adamsen L. Patient education. A strategy for prevention of infections caused by permanent central venous catheters in patients with haematological malignancies: a randomized clinical trial. J Hosp Infect 2005;61:330-41. 26. Kizer KW. Patient centred care: essential but probably not sufficient. Qual Saf Health Care 2002;11:117-8.
Contents lists available at ScienceDirect
American Journal of Infection Control
American Journal of Infection Control
journal homepage: www.ajicjournal.org
Major article
Parent willingness to remind health care workers to perform hand hygiene Genevieve L. Buser MDCM, MSHP a, *, Brian T. Fisher DO, MSCE a, Judy A. Shea PhD b, Susan E. Coffin MD, MPH a a b
Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA
Key Words: Health care-associated infections Patient safety Pediatric Family-centered care Positive deviance
Background: Health care worker (HCW) hand hygiene (HH) is the core strategy to prevent health careassociated infections (HAI). Suboptimal HCW HH rates continue despite hospital efforts to increase compliance. Objectives: To determine whether parents of hospitalized children perceive they have a role in preventing HAI and whether they are willing to remind HCW to perform HH, with and without an invitation. Methods: We conducted structured interviews of parents of children admitted to a pediatric hospital. Questions assessed knowledge, attitudes, and behaviors about HAI and HH. The primary outcome was willingness to remind a HCW to do HH (5-point Likert scale). Results: We interviewed 115 parents, of whom 84% were aware of HAI. Most parents (78%) perceived HH as the most important practice to prevent HAI. However, only 67% would definitely remind a HCW to perform HH. Importantly, 92% said that an invitation from a HCW would make them more likely to remind a HCW to do HH in the future. Conclusion: Our results suggest that parents of hospitalized children are willing to help prevent HAI; however one-third are still reluctant to remind HCW to perform HH. An invitation by HCW to parents to remind HCW to perform HH might effectively engage parents as partners in HAI prevention. Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc.
Proper hand hygiene (HH) is the cornerstone of multiple evidence-based strategies to prevent health care-associated infections (HAI).1-3 High levels of adherence to HH by health care workers (HCW) are difficult to sustain because HH requires a change in behavior, requires frequent repetition, and competes with other tasks for time and attention.4,5 One strategy to increase HH is through direct observation and real-time feedback.6-8 Patient participation is a mechanism to provide direct observation and feedback to HCW about HH.1,3,9,10 However, studies to assess patient reminders to HCW to perform HH have demonstrated a gap between willingness and action.11-13 Among adult inpatients, 70% reported being worried about the risk of HAI; however, only 41% of respondents thought that a patient should remind HCW to cleanse their hands.11 Even fewer (22%) said they would be comfortable reminding a nurse or physician to perform HH. Inaction may be related to professional status (ie, questioning
* Address correspondence to Genevieve L. Buser, MDCM, MSHP, Oregon Public Health Division, 800 NE Oregon Street, Portland, OR 97232. E-mail address: [email protected] (G.L. Buser). Conflicts of interest: None to report.
authority) and seniority (ie, less likely to remind a physician compared with a nurse).11,14-16 Thus, knowledge alone is insufficient to ensure patient participation in HAI prevention. Although patient participation in health care behaviors begins with knowledge (ie, HAI prevention by HH), an opportunity and decision to intervene are required to lead to the desired behavior (ie, reminding a HCW to perform HH).1,17,18 Encouraging patient self-efficacy may diminish the barrier between intention and action.1,3,12,17 An invitation to remind HCW has been proposed as a mechanism to empower patient intervention by diminishing perceived barriers and modeling desired outcome (eg, positive deviance).8,11,14,19 For example, an invitation by a HCW to an adult patient to remind the HCW to wash their hands more than doubled the patients’ intention to intervene (30% to 78% for physician HCW).11 We wanted to assess how parents might be engaged by invitation to increase HCW HH in a pediatric health care setting. Such an invitation from HCW to parents to collaborate in HAI prevention is consistent with family-centered care, a cornerstone of pediatric health care delivery.20-22 We performed a study to describe parental knowledge, beliefs, and intentions toward HCW HH and to further investigate whether parent participation in HAI prevention is acceptable to parents. In
0196-6553/$00.00 - Published by Elsevier Inc. on behalf of the Association for Professionals in Infection Control and Epidemiology, Inc. http://dx.doi.org/10.1016/j.ajic.2012.08.006
G.L. Buser et al. / American Journal of Infection Control 41 (2013) 492-6
addition, the study was designed to assess whether an invitation from a HCW would increase the likelihood that the parent would remind the HCW to perform HH. METHODS Study design and population We conducted a cross-sectional, structured interview of parents of hospitalized children at the Children’s Hospital of Philadelphia, an academic, quaternary children’s hospital with 460 beds in Philadelphia, PA. The study protocol was approved by the Institutional Review Board. Study subjects A pool of potential participants was identified by a review of daily admission logs between October 26, 2010, and December 18, 2010. Potential participants were selected from among new admissions to nonintensive care units using a random number generator. Parents or guardians were eligible for participation if they (1) spoke English and (2) their child had been admitted less than 48 hours prior to survey administration. Structured interview Eligible parents were approached at the bedside, invited to participate, and verbally consented to be interviewed. The questionnaire was adapted from a study specific to adult inpatients. The adapted version contained 40 questions, in multiple-choice, 5-point-Likert-scale or short-answer formats.11 The adapted questionnaire was piloted on 10 families and revised accordingly. Interviews were performed using a visual aide to assist with comprehension. Interview topics included the following: (1) parent and child characteristics, including past hospitalizations and chronic medical conditions; (2) parent knowledge about HAI prevention; (3) evaluation of the parent’s intention to intervene to remind HCW to perform HH (Likert scale); and (4) motivators or barriers to parent intervention (open-ended). Age, history of past hospitalization, history of chronic medical condition, and history of HAI were collected for both the parent and the child. Data on relation to the patient, race, ethnicity, education, and health care employment were collected about parents. Specific patient risk factors for HAI were collected for the child. Definitions A chronic medical condition was defined as an illness lasting 3 months that impacts the patient’s normal activities and requires frequent treatment. A risk factor for HAI was defined as an indwelling medical device (eg, endotracheal tube, central venous catheter, and urinary catheter), surgical incision, implant, or organ transplant during the current admission. Health care facility employment was defined as having worked or volunteered in a clinic or hospital. Knowledge of correct HH technique was defined as washing with soap and water for a minimum of 15 seconds. Intention to intervene was assessed by a hypothetical situation: “If you saw that the doctor or nurse had not washed their hands prior to examining, taking vital signs, or giving medication to your child, how likely would you remind them to wash their hands?” Likert scale choices used the following format: “definitely not likely,” “unlikely,” “neither,” “somewhat likely,” “definitely likely.” This was followed by an explicit invitation: “If a doctor or nurse said to you, ‘Please remind me to wash my hands’ when they introduced
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themselves, would you be more or less likely to remind them in the future?” After reviewing the distribution of scale responses, the following groupings were used: a response of 1 or 2 was coded as negative; a response of 3 was coded as neutral; a response of 4 or 5 was coded as affirmative. Open responses were grouped into common themes and reported as frequencies. Statistical analysis Descriptive analysis Categorical variables are presented as frequencies, and continuous variables are summarized by mean or medians when appropriate. Ordinal variables (eg, Likert 5-point scales) were expressed using frequencies, medians, and percentages. Cronbach a was <.8 for the main domains of the survey. Comparative analysis This study had 2 distinct comparative outcomes. The first was to compare parents’ willingness to remind a HCW to perform HH before and after an invitation. The second was to compare parents reporting a definite intention to remind HCW tp those without a definite intention. For comparative analyses, 5-point Likert scale responses were dichotomized. Univariate comparison of categorical variables was performed using the Pearson c2 or Fisher exact test (if frequency of events 5). Comparison of continuous variables was executed using the Student t test. The explanatory variables significantly associated with the outcome of interest and those with a plausible correlation to the outcome a priori were included in stepwise fashion to a multivariate logistic regression model. All analyses used 2-tailed tests and 95% confidence intervals; P values <.05 were considered significant. Sample size and power Based on previous research, we estimated that 30% of parents would remind the HCW to perform HH at baseline, and an additional 30% would do so after an invitation.11 Assuming each subject’s responses represented a matched pair (before and after an invitation), a sample size of 115 subjects would achieve 80% power to detect an odds ratio of 3, if the true difference before and after the intervention was at least 20%, using a 2-sided McNemar test with a significance level of .05. Statistical analysis was performed using Stata Version 11 (StatCorp LP, College Station, TX). RESULTS Four hundred six potential participants were selected from admission lists; 115 (28%) parents were consented and interviewed. Nonparticipation occurred for the following reasons: parent was unavailable, or patient was discharged (230/406, 57%); inconvenient time (31, 8%); parent specifically declined to be interviewed (20, 5%); non-English speaking parent (10, 3%). Nonparticipants did not differ significantly from participants in terms of patient’s age, gender, uninsured status, or general versus specialty unit status. Characteristics of interviewed parents The characteristics of interviewed parents and children are summarized in Table 1. Most parents were mothers (92/115, 80%), white (57%), non-Hispanic (87%), and between 35 and 44 years of age (35%; range, <18 to >60 years). More than two-thirds (77%) completed at least some college or trade school. A substantial proportion of parents (43%) had ever worked or volunteered in a health care facility. Five parents (4%) reported an HAI in the past.
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Table 1 Selected parent and child characteristics, N ¼ 115 Characteristic Age Race, n (%)
Highest education level, n (%)
Chronic medical condition, n (%) Hospital experience, n (%)
HAI risk factor during admission, n (%)
Previous HAI
Median (range) White Black Other Hispanic Less than high school High school diploma/GED Some college/trade/AA 4-year college degree or greater Yes Hospitalized previously, ever Hospitalized >7 times Hospitalized >5 days
Parents
Children
35-44 years (18-60þ years) 66 (57) 34 (30) 15 (13) 15 (13) 4 (4) 23 (20) 44 (38) 44 (38) 30 (26) 80 (70) 8 (7) 30 (26)
6 years (1 mo to 18 years) –
1 Risk factor 2 Risk factors 3 Risk factors Yes
–
5 (4)
– –
69 81 21 47
(60) (70) (18) (40)
40 22 12 13
(35) (19) (10) (11)
AA, Associates degree; GED, general equivalency diploma; HAI, health care-associated infection.
Characteristics of children Children were aged 1 month to 18 years (right-tailed: median, 6.0 years; interquartile range, 1.2-11 years). More than half (60%) had chronic medical conditions, the most common being asthma (22/69, 32%), gastrointestinal disorder (18, 26%), immunocompromised condition (14, 20%), and neurologic syndrome (8, 12%). More than one-third of the children (35%) had 1 risk factor for HAI present during this hospitalization, and 19% had 2 risk factors for HAI. Thirteen children (11%) reported 17 episodes of HAI. Parental knowledge, perceptions, and intentions toward preventing HAI Parental knowledge, perceptions, and intentions toward preventing HAI are summarized in Table 2. More than two-thirds of parents (71%) believed they play an important role in preventing HAI in general. The majority of parents correctly identified HH as the most important intervention to prevent HAI (78%). However, less than half (44%) described proper hand hygiene. Parents reported that they received information about the hospital’s HH campaign by poster (68%), Web site (20%), HCW (14%), television (14%), or brochure (12%). The majority of parents reported being definitely willing to help improve HH in HCW (75%), but fewer would definitely act to remind a HCW to wash their hands (67%). However, 78% reported that they would definitely be more likely to remind a HCW to do HH after an invitation. After adjusting for age, education, history of chronic medical condition, prior hospitalizations, and experience working in health care, parent willingness to help prevent HAIs (adjusted odds ratio [aOR], 5.78; 95% confidence interval [CI]: 2.2-15.16; P < .0001) and belief that they had an important role in improving HH in HCW (aOR, 4.76; 95% CI: 1.64-13.77; P ¼ .004) were independently associated with a parent’s definite intention to remind a HCW to wash their hands.
Table 2 Knowledge, perception and intentions of parents of hospitalized children, N ¼ 115 Knowledge Aware of HAI prior to interview Identified importance of HH to prevent HAI Reported correct handwashing technique* Perceptions HAI would be a serious risk to child’s health Parents have an important role in preventing HAI Parents have an important role in improving HH in HCW Intentions Definitely willing to help improve HH in HCW Definitely likely to remind a HCW to perform HH Given an explicit invitation, definitely more likely to remind a HCW to do HH Actions Have previously reminded a HCW to wash their hands
n (%) 96 (84) 90 (78) 50 (44) 90 (78) 82 (71) 59 (51) 86 (75) 77 (67) 90 (78)
24 (21)
HAI, hospital-associated infection; HCW, health care worker; HH, hand hygiene. *Washing with soap and water for a minimum of 15 seconds.
to have worked in a health care facility (aOR, 4.39; 95% CI: 1.5912.16; P ¼ .004). Motivators and barriers Motivators and barriers to reminding HCW to perform HH were grouped by themes. Of those who reported barriers, the most common was a concern for “appearing rude or undermining authority” (11, 10%), followed by “assuming the HCW should know” (9, 8%), and an “intimidating manner by the HCW” (9, 8%). Parents also suggested motivating factors: “HCW gives an invitation or introduces topic” (17, 15%); “HCW is approachable and friendly” (13, 11%); parent witnesses an “unsanitary act or high-risk situation” (12, 10%); and there is “signage to remind parents to do HH” (5, 4%). Three parents (3%) interpreted the reminder as a lack of professionalism.
Parental actions toward improving HH
DISCUSSION
Twenty-four parents (21%) reported reminding a HCW to wash their hands in the past. On multivariate analysis adjusted for age, education, chronic medical condition, and prior hospitalizations, parents who had reminded HCW to perform HH were more likely
In this study, we found that parents were willing to help improve HH in HCWs. An explicit invitation was associated with increased willingness by parents to remind HCW to perform HH. Parents who believed they have a role to improve HH in HCW
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were more likely to have reminded a HCW to perform HH in the past. These findings build on existing literature about encouraging parent self-efficacy and promoting family-centered care, in which parents are invited to partner with their child’s medical team.20-23 Parents in this study were more likely to believe that they had a role in preventing HAIs and were more willing to remind HCW to wash their hands than adult patients in other studies.11,13,16 Also, 20% of parents reported having reminded a HCW in the past to perform HH, as compared with <10% of adult patients.11,13 A person’s decision to intervene in a positive health behavior is most influenced by outcome expectancies (ie, an action will result in a beneficial outcome) and self-efficacy (ie, the ability to influence one’s situation).18 We hypothesize that parents might be more likely to intervene because of their role as protector and advocate for their child, which might translate into higher outcome expectancies and self-efficacy. Thus, parents might be willing partners to engage to help prevent HAIs in the hospital.7 An invitation from a HCW was associated with an increase in the willingness of parents to remind a HCW to perform HH in the future. This is congruent with studies suggesting that reminders to HCW by patients might decrease social barriers caused by HCW professional status and seniority.3,14,15 McGuckin et al found that patient-initiated questioning of staff “Did you wash your hands?” increased HH long-term by 40% in an adult acute care hospital ward.24 An invitation from a HCW might diminish any perceived barriers to intervention and might encourage patient or parent participation. Parent participation in HAI prevention corresponds to principles of family-centered care by encouraging self-reliance in families and ensuring patient safety with continual HAI quality improvement by the health care team.20-23 Fundamental to any HAI improvement is an environment of safety where “the consideration of hand hygiene improvement [is] a high priority at all levels.”3 Parents are a part of the environment of safety: they are present at their child’s bedside and motivated to positively participate in their child’s hospital care. Parents can be taught basic preventative measures to prevent HAI (eg, 5 Moments of HH, central line care, and others).9,10,16,25 For example, applying the theories of “positive deviance,” HCW can model correct HH technique to parents and invite them to participate in HAI prevention practices, while reinforcing evidence-based practices by normalizing HH observation and feedback.8,19 Despite the potential benefits, a small number of parents had a negative response to the hypothetical intervention in this study. Some critics have expressed concerns about involving parents in HAI prevention.26 For example, parent involvement could make additional demands on HCW because parent education requires extra time by staff. Furthermore, parents and staff may perceive this oversight as policing rather than collaborating with HCW. However, these are theoretical barriers to parent involvement that could be addressed by proper implementation strategies (ie, close collaboration with family advocacy groups).3 Limitations We were unable to make robust statistical conclusions on the effect of an invitation to remind HCW to perform HH because we found a higher than expected positive parent involvement at baseline. Given the unexpected high positive response by parents to remind HCW to wash their hands prior to an invitation, the power to detect a difference before and after an invitation was only 0.463. However, this is an encouraging finding: the majority of parents is motivated to intervene on their child’s behalf to
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encourage HH in HCW. Our findings might not be generalized because the study occurred at a single center, and nonparticipants may have been different than participants by an untested parameter. Third, there is a potential framing bias: asking about HAIs implies importance, which might have influenced parents to overestimate their intentions. Conclusion Our results suggest that parents are willing and motivated to partner with HCW to prevent HAI in their children. A parentHCW HAI collaboration could improve child health by empowering parents to participate in HAI prevention efforts and remind HCW to wash their hands. In addition, HCW can promote parent partnerships by inviting participation and teaching correct HH technique. Together, willing parents and HCW could promote a culture of change to achieve improved HH compliance and prevent HAI. Acknowledgments We thank Brian Smith, Children's Hospital of Philadelphia; Judith Long, MD, University of Pennsylvania.
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