104


Table 2. Healthcare Personnel Hand Hygiene Observations and Compliance Observations, No. (%)


Occupation Registered nurse


Licensed independent practitionera Nursing assistant Other


(n=4,600) 1,906 (41) 756 (16) 737 (16)


1,201 (26) aIncludes physician, physician assistant, advanced practice registered nurses, etc.


observed more frequently among registered nurses (47%) than LIPs (2%) and nursing assistants (29%). Independent of the secret-shopper observations, 32 individual


HCP were interviewed immediately after observing their use of gloves without HH performance. Staff interviewed were primarily RNs (15, 47%), technicians (5, 16%), and nursing assistants (4, 13%).


Interviews identified 4 major themes as drivers of glove use:


protection and safety of staff and patients, availability of gloves, previous medical training guidance, and barriers to HH. In the 32 interviews, the word “protect” was mentioned by healthcare workers 14 times and the words “safe,”“safer,” and “safety” were mentioned 25 times. Additionally, the availability of gloves in terms of their close proximity to patients’ rooms was noted as a facilitator for glove use. Many nursing staff stated that they were taught in their professional training that gloves should be used on a more universal basis. Other barriers to performing HH also emerged through


interviews including workload, distance to hand-washing sinks, and growing use of hospital-supported cell phones. Facilitators to HH included awareness of the importance of HH and the high density of ABHR dispensers across patient care areas. Addition- ally, successful hospital-initiated interventions mentioned in interviews included the implementation of “Hand Hygiene Champions,” the addition of signs providing HH guidance, and the accessibility of gloves and ABHR in patient care areas.


Discussion


Overall, compliance with HH was high among HCP. Gloves were found to be a potential barrier to HH and use in lieu of HH was greatest among nursing staff. Glove use was shown to be driven by staff desire for personal safety and potentially learned during professional training. We particularly noted HCP understanding of the importance


HH may prove useful in increasing HH compliance. Girou et al3 showed that HH did not take place due to improper glove usage in 64.4% of cases, and Loveday et al4 demonstrated that glove use was inappropriate in 42% of episodes. In our study, many staff wore gloves at unnecessary times such as a physical therapist ambulating a patient, a nurse pushing a “workstation on wheels,” and a nurse administering medications to patients who were not on contact precautions.


of HH in protecting patients and staff. Additionally, recognition of interventions to increase HH on hospital units, such as ABHR accessibility and signage, demonstrates that the hospital’s emphasis on infection prevention and HH resonated with staff. Re-education among HCP promoting proper glove usage and


Cell phone usage has emerged as a barrier to performing HH


and reflects a growing concern about cell phones as a risk for the transmission of microorganisms.5 Described in our interviews as a “barrier” and “setback,” cell phones are increasingly used in healthcare settings to promote efficient communications. A 2015 study demonstrated that 100% of all tested phones collected from patients and HCP were contaminated with either single or mixed bacterial agents.6 Adaption of specific policies and/or work pro- cesses regarding cell phones and HH for HCP may help to mitigate concerns. Through interviews, many HCP mentioned previous training


for their profession as a main driver for glove usage. Glove use and the concern for safety may reflect a knowledge deficit about the limitations of glove use and effectiveness of HH and a need to assess the appropriateness of how schools of nursing and allied personnel are teaching students about these topics. One possible limitation is the generalizability of the findings,


as the study was conducted in the inpatient setting at a single academic medical center. Second, because the selection process for interviewing HCP occurred without the benefit of under- standing whether he or she was anticipating contact with body fluids, we may have inadvertently captured HCP in situations for which glove use was indicated. However, many HCP upon interview were noted to be wearing gloves at unnecessary times without apparent indication. Additionally, few LIPs agreed to be interviewed. However, our quantitative data demonstrate that glove use did not appear to be a major barrier to HH among LIPs. This finding mirrors previous studies in which the rate of glove use was lower among physicians (4.5% of opportunities) than among nurses (31.2%).7 Finally, it remains unresolved whether HH prior to donning gloves decreases risk for pathogen exposure and/or transmission.8 This is an area of active investigation. In conclusion, glove use was a potential barrier to HH and was


most pronounced among nursing staff. Main drivers for this practice were personal safety, previous medical training, work- load, distance to sinks, and cell phones. A more complete understanding of the drivers of behaviors limiting HH may lead to more effective interventions to improve HH performance by HCP.


Acknowledgments. We thank the employees and medical staff of Yale New Haven Hospital and the Yale New Haven Hospital Hand Hygiene Perfor- mance Improvement Team for their support of this project and efforts to improve patient safety.


Financial support. No financial support was provided relevant to this article.


Conflicts of interest. J.M.B is a consultant to, and has received travel sup- port from, Diversey and GOJO Industries, and he has received research funding from GOJO Industries. R.A.M. has received nonfinancial research


Wash-in (n=2,180) 678/926 (73) 362/384 (94) 143/286 (50) 442/584 (76)


Blake A. Acquarulo et al


Compliance, n/N (%)


Wash-out (n=2,419) 777/981 (79) 353/373 (95) 306/449 (68) 396/616 (64)


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