Category: Hygiene

Introduction

The idea of getting nurses and physicians to observe hand hygiene is not new. The Hungarian physician, Ignác Fülöp Semmelweis (18181865) first tried this approach in the 1840s when he elaborated the importance of hand hygiene among physicians to prevent the spread of pathogens (Samuel, Almedom, Hagos, Albin & Mutungi, 2005). However, the medical community did not support the physicians recommendations. The physician noted that when health workers washed their hands thoroughly and frequently, they could avoid infections and save lives. It appears that from 1840s to the present, little or nothing has changed because hospital-associated infections have continued to rise across various health care facilities. Hand hygiene practices in health care facilities refer to handwashing with any form of approved antimicrobial disinfectants, soaps, or alcohol-based disinfectants.

One major puzzle is why health care workers have failed to observe simple hand hygiene practices. The Joint Commission has recognized that measuring health care worker adherence to hand hygiene practices is not a simple matter due to differences in opinions and misinformation (Joint Commission, 2009). It noted that evaluating the what, when, why, and how in hand hygiene performance was a challenging task. Moreover, health care workers needed to understand when to make decisions about hand hygiene. The Commission also acknowledged studies, which had indicated that adherence to hand hygiene practices and recommendations remained poor while any positive outcomes were often unsustainable (Joint Commission, 2009).

Generally, many studies have touted proper hand hygiene as the simplest and most effective mode of preventing hospital-related infections (Joint Commission, 2009; Samuel et al, 2005). These are mainly infections, which patients acquire during their stay at the hospital. One must recognize that patients are most prone to hospital-associated infections. Many of these infections are caused by common pathogens, including multi-drug resistant ones. These pathogens may result in bloodstream infections, pneumonia, urinary tract infections, and even surgical site infections.

This study is a critique of evidence in hand hygiene as best practice in adult care nursing.

Current practices and Outcomes in Hand Hygiene

Both past studies (Doebbeling et al, 1992) and current studies have noted the presence of hospital-associated infections (HAIs), which have presented major threats to patient health and safety and they are related to cases of mortality that ranged between 5% and 35% (Flodgren et al, 2013). In addition, they also accounted for patient morbidity in the intensive care unit (ICU).

There are critical risk factors that studies have associated with HAIs. They include the use of invasive medical instruments and techniques and poor adherence to infection prevention guidelines among health care workers during such medical procedures. These could be life-threatening medical cases and surgical procedures. There are certain risk factors for every device, but a general approach concentrates on the use of medical devices and the length of use, which determine the extent of infections to patients alongside organisms that cause infections (Flodgren et al, 2013). In most cases, these organisms are transmitted to patients through the hands of physicians or nurses during medical procedures. On the same note, outbreaks also occur in patients and transmission takes place from one patient to another through contaminated medical devices. Some of these pathogens have abilities to survive on hands for more than two hours (Doebbeling et al, 1992).

Since the period of Semmelweis, hand hygiene has proved to be effective in controlling cases of nosocomial infections among patients. Therefore, health care workers can control and interrupt the spread of many infections by observing proper hand hygiene practices (Doebbeling et al,1992). As in the past, the promotion of simple, effectual and affordable guidelines of hand hygiene continue to record gradual progress because of poor human behaviours associated with ignorance, attitudes, carelessness or arrogance among health care providers despite their levels of academic qualifications. In most cases, health care stakeholders have issued, revised, and improved hand hygiene guidelines regularly. In addition, there are ongoing education, technical training on hand washing, novel approaches and incentives for health care workers to observe hand hygiene (Hartocollis, 2013), yet the issue of hand hygiene continues to remain unresolved and persistent. Samuel et al. (2005) noted that worst cases of poor hand hygiene were noted among doctors working in ICUs, emergency areas, and post anaesthesia care units (PACU) in which there were several, highly susceptible patients. Further, some data from self-reports among doctors and gynaecologists have indicated poor adherence with justifications that range from a lack of adequate time to personal belief that hand hygiene have little or no health values to patients. Consequently, there have been a series of heated debates about the effectiveness of hand hygiene. On the other hand, one must recognise that a great many extremely qualified physicians, nurses and other health care providers strive to observe and promote hand hygiene in their institutions irrespective of little time and limited resources.

Therefore, hand hygiene contributes to major challenges in the provision of quality health care and improved outcomes for patients. This could provide accounts of patients susceptibility to hospital-associated infections despite advancements made in the health care sector (Mani, Shubangi & Saini, 2010).

As cases of nosocomial infections increase, academics and professions have questioned health care delivery and hygiene standards in hospitals because many studies have noted the relevance of hand hygiene in combating hospital acquired infections (Akyol, 2007).

Why are health care workers so poor at hand hygiene?

As noted earlier, some of the health care workers continue to perform dismally at hand hygiene practices. According to Hartocollis (2013), various studies have provided different accounts on poor hand hygiene practices among health care workers, which included dry skin, the pressures of an emergency environment, the tedium of hand washing and resistance to authority (doctors, who have the most authority, tend to be the most resistant, studies have found) (Hartocollis, 2013).

However, despite several cases of infections associated with hand hygiene, hand hygiene practices among physicians and nurses have remained unacceptably poor (Akyol, Ulusoy & Ozen, 2006; Samuel et al, 2005; Hartocollis, 2013). Studies have shown that hand hygiene practices in developed nations hardly achieve 50 percent compliance (Maxfield & Dull, 2011). Consequently, poor observation and compliance with hand hygiene guidelines have resulted in increased cases of morbidity and mortality (Flodgren et al, 2013). Such cases have led to increased medical costs. For instance, in the USA, there are at least 100,000 patient deaths every year associated with poor hand hygiene while the cost for hospital-acquired infections has reached $30 billion (Hartocollis, 2013). Under the new Federal rules on preventable infections, health care facilities will not receive Medicare compensation if patients suffer such nosocomial infections. Consequently, hospitals are willing to embark on extreme measures to ensure effective hand hygiene practices and reduce cases of transmission.

Cases of nosocomial infections vary from country to country. However, the simple yet complex hand hygiene remains the most effective and affordable method of controlling transmissions and reducing infections in hospitals. Various health care organisations have emphasised the relevance of hand hygiene practices in health care settings to reduce infections and related health complications and costs.

Hand hygiene in health care settings is critical because physicians and nurses who are exposed to medical devices and patients often are contaminated. Health care facilities should provide safety and promote recovery rather than infections among patients and health care workers. Therefore, the main goal of hand washing is to eliminate dirt, germs, reduce the presence of microorganisms on the skin and prevent transmissions of pathogens from health care workers to patients.

Nurses and physicians should comply with hand hygiene practices because of their working environments and patient safety. Moreover, there are obligatory roles that require nurses to observe hygiene in the course of their duties for their own safety and patients well-being. At the same time, nurses must act professionally, ethically and be responsible for their patients. The code of standards defines all conditions that nurses must meet when delivering care to patients. However, despite intense campaigns to observe hygiene and promote patient safety and outcomes, some nurses and doctors still disregard hand hygiene practices and guidelines and consider any infection as a part of patient infections, which they will handle (Maxfield & Dull, 2011). As noted above, several factors have contributed to poor hand hygiene practices among nurses and physicians. In addition, health care workers have to remember several procedures. Therefore, they might find it simple to forget easy, basic tasks like hand hygiene. At the same time, other health care providers have recognised hand gloves as alternatives to hand washing (Nazarko, 2009). Under such cases, they tend to use a single glove for multiple purposes and fail to wash their hands after medical procedures. In addition to dry skin cases, nurses also avoid hand washing for fear of developing skin conditions like dermatitis, particularly when they use alcohol-based sanitizers.

It is imperative for health care providers to observe hand hygiene before performing any intrusive medical procedures. After such procedures, contacts with contaminated medical instruments and with highly vulnerable patients should be limited. In this case, hand hygiene should be conduct before and after all medical procedures (Kampf & Loffler, 2010). Nurses may also note that hand hygiene requirements and practices may differ from one procedure to another, based on the extent of contamination and the resistance of pathogens on the skin. This may also raise the question of hand hygiene guidelines even if health care providers spend maximum time washing their hands. In other words, nurses must also learn how to perform hand-washing techniques because they may fail to wash their fingers, nails, thumbs and wrists among others properly.

Studies have noted poor practices in hand hygiene among doctors relative to nurses (Akyol, Ulusoy & Ozen, 2006; Samuel et al, 2005; Hartocollis, 2013). Thus, the rate of hand hygiene practices among health care workers differed considerably.

On this note, researchers have noted that attitudes and behaviours among nurses and doctors could have significant impacts on observing hand hygiene practices (Ott & French, 2009). In this case, health care workers have questioned the effectiveness of hand washing. In addition, personal values and belief systems are a part of barriers that hinder effective adoption of hand hygiene guidelines.

One may wonder how health care workers can promote and achieve favourable impacts in hand hygiene practices. In this case, it is necessary to track hand hygiene practices, teach staff, reward best performers and punish defaulters as if they have dishonoured critical health care policies. Overall, nurses and physicians require thorough education and training on hand hygiene practices.

The practice in hand hygiene should not be restricted to nurses alone. Instead, all hospital stakeholders, including patients and leaders should promote hand hygiene practices at their levels. Therefore, patients and nurses should promote hand washing by enquiring if they do actually observe the practice. However, the extent of enquiring about hand hygiene between patients and their health care providers could be difficult to determine. Nurses and physicians must recognise that patients value their trust and feel reassured if they observe good hand hygiene practices.

While other studies have cited poor attitudes, behaviours and lack of time for health care workers to observe hand hygiene, other studies have cited a lack of scientific knowledge and awareness as major contributors to poor hand hygiene (Akyol, 2007; Mani et al, 2010). In this case, training opportunities have failed to introduce nurses to practical aspects of hand washing and observation with patients in real-life situations. Still, Ott and French (2009) noted that health care workers attitudes and cultures during their duties had a significant impact in their clinical training and development. Some of these habits could have originated from trainers who demonstrated poor hand hygiene training. They tended to be busy and had little time for effective hand washing practices. Nurses and physicians undergo training on recommended approaches of controlling and limiting infections, including precautions they must observe (Ott & French, 2009). However, the training programmes do not emphasise hand hygiene throughout the study period. On this note, it is important to remind nurses of precautions that can limit transmission of pathogens to patients. At the same time, it is necessary for health care stakeholders to organise education programmes and seminars to emphasise the importance of hand hygiene for health care workers and patients (Nazarko, 2009). Such training programmes can reinforce compliance and enhance best practices in health care provision.

Another factor that has led to poor outcomes in observing hand hygiene is misconception about the practice. This may involve situations in which nurses and doctors use gloves to substitute hand washing. In addition, they have also claimed that certain skin conditions arise from frequent hand washing with some hand washing gels (Mani et al, 2010). Moreover, nurses and physicians have experienced increasing workloads, constrained time, few staff, lack of mentoring from seniors, organisational support, different views about the recommended hand hygiene practices, and poor motivation (Akyol, 2007). These factors have contributed to poor outcomes in hand hygiene practices (Mani et al, 2010). In addition, some facilities lack adequate or recommended hand hygiene facilities and products. Such provisions include running water, antiseptic soaps, hand or paper towels and alcohol-based hand scrubs. The situation has become unbearable in developing nations, which may lack even proper facilities for patient care. Thus, their outcomes in hand hygiene practices remain unacceptably poor.

Interventions to promote hand hygiene among health care worker

From the literature reviewed and critiqued, there are several factors, which have contributed to poor hand hygiene among health care workers. These studies have presented various accounts of the problem of observing hand-washing practices. However, according to Gould, Moralejo, Drey and Chudleigh (2010), the qualities of intervention studies, which are intended to enhance hand hygiene and compliance among health care workers have remained low. While some interventions have achieved some positive effects, there are insufficient data to attribute such approaches to improved hand hygiene campaigns among health care workers. Hence, one cannot draw a firm conclusion based on such claims. Consequently, these researchers have concluded that there is an urgent need to undertake methodologically robust research to explore the effectiveness of soundly designed and implemented interventions to increase hand hygiene compliance (Gould et al., 2010).

Bischoff, Reynolds, Sessler, Edmond, and Wenzel (2000) noted that education and feedback interventions had positive effects among health care workers in different units. For instance, a baseline study of hand hygiene compliance among health care workers revealed that medical ICU recorded an improvement from 9 percent to 22 percent, whereas those in cardiac surgery ICU noted an improvement of 10 percent from 3 percent. However, after the education/feedback intervention initiative, there were notable improved outcomes. Hand washing compliance improved from 14 percent to 25 percent in medical ICU and from 6 percent to 13 percent in cardiac surgery ICU. This was possible because of changes made in the facility, which included the introduction of accessible hand hygiene facilities and products. It resulted in high rates of hand washing among health care workers. Therefore, the researchers concluded that education/feedback intervention and patient awareness programs did not increase hand washing compliance, whereas the introduction of easily accessible dispensers with an alcohol-based waterless hand washing antiseptic led to significantly higher hand washing rates among health care workers (Bischoff et al, 2000). Therefore, education to enhance hand washing practices and compliance must be supported with the necessary hand hygiene products and facilities.

On this note, intervention programmes should focus on specific problems and adopt task-oriented strategies alongside education and feedback to enhance hand hygiene compliance.

Studies also cited a lack of adequate time for observing hand hygiene among nurses. In this regard, intervention programmes should promote clustering of nursing procedures and reducing handling of medical devices. This would overcome time barriers as Lam, Lee and Lau (2004) noted. In addition, constant auditing and regular feedback could help in sustaining the adopted compliance procedures. Moreover, based on the Joint Commission recommendations, health care facilities should develop measures for evaluating the effectiveness of hand hygiene practices (Joint Commission, 2009). On this note, Hartocollis (2013) noted that some health care facilities have turned to technologies to track and provide feedback on hand hygiene practices among their health care workers. Such systems provide immediate feedback on defaulters. Therefore, intervention programmes should consider technologies in tracking hand hygiene practices among health care workers.

Studies recognised that hand hygiene was the most effectual and affordable means of controlling hospital-associated infections. However, Jumaa (2005) noted that relying on hand hygiene alone to improve practice in health care setting and control infections might not yield the desired outcomes. There were other factors, such as environmental, staffing needs, education and training to consider in hand hygiene intervention programmes. Therefore, hand hygiene practices should be integrated with other intervention programmes to limit the spread of nosocomial infections.

Studies have asserted that compliance with hand hygiene guidelines has remained poor throughout the world (Jumaa, 2005). The processes of hand hygiene are rather simple. However, there are other interdependence factors, which affect behaviours and result in poor outcomes. On this note, intervention programmes must focus on changing human behaviours. Therefore, contributions from behavioural science in intervention programmes could help in addressing negative attitudes towards hand hygiene practices among health care workers. Moreover, such intervention programmes should also account for social and cultural needs of different groups (Akyol et al, 2006).

Conclusion

Literature reviewed and critiqued has shown that hand hygiene practices can limit the transmission of nosocomial infections among patients. These studies have also shown that hand hygiene guidelines are simple, but many health care workers have failed to sustain the recommended guidelines. Consequently, there are cases of morbidity and mortality linked to hospital-associated infections.

Nurses and physicians have failed to adhere to hand hygiene guidelines. Studies have identified several factors, which include lack of adequate time, poor attitudes and behaviours, lack of adequate hand hygiene products and resources, scientific knowledge and training on effective hand washing techniques, differences in personal beliefs and the recommended guidelines among others.

Based on these observations, it is clear that intervention programmes to enhance effective hand hygiene among health care workers must be multifaceted with a clear focus on individual and facility related factors. Such intervention programmes must include continuing health care worker training, reviewing of current practices, constant feedback, the use of technology and enhancing access to hand hygiene products and facilities. In addition, all stakeholders must participate in hand hygiene in health care settings. Specific interventions must focus on low staffing and time management. Unless health care workers change their behaviours, hand hygiene practices and outcomes will remain dismally low.

References

Akyol, A, Ulusoy, H & Ozen, I 2006, Handwashing: a simple, economical and effective method for preventing nosocomial infections in intensive care units, Journal of Hospital Infection, vol. 62, no. 4, pp. 395-405.

Akyol, A 20072, Hand hygiene among nurses in Turkey: opinions and practices, Journal of Clinical Nursing, vol. 16, pp. 431-437.

Bischoff, W, Reynolds, T M, Sessler, C N, Edmond, M B & Wenzel, R P 2000, Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic, Archives of Internal Medicine, vol. 160, no. 7, pp. 1017-21.

Doebbeling, B, Stanley, G, Sheetz, C, Pfaller, M, Houston, A, Annis, L, Li, N & Wenzel, R 1992, Comparative Efficacy of Alternative Hand-Washing Agents in Reducing Nosocomial Infections in Intensive Care Units, New England Journal of Medicine, vol. 327, pp. 88-93. Web.

Flodgren, G, Conterno, O, Mayhew, A, Omar, O, Pereira, R, & Shepperd S 2013, Interventions to improve professional adherence to guidelines for prevention of device-related infections, Cochrane Database System Review, vol. 3, pp. CD006559. Web.

Gould, D J, Moralejo, D, Drey, N &Chudleigh, J H 2010, Interventions to improve hand hygiene compliance in patient care, Cochrane Database System Review, no. 9, pp. Web.

Hartocollis, A 2013, With Money at Risk, Hospitals Push Staff to Wash Hands, The New York Times, Web.

Joint Commission 2009, Measuring Hand Hygiene Adherence: Overcoming the Challenges. Web.

Jumaa, P 2005, Hand hygiene: simple and complex, International Journal of Infectious Diseases, vol. 9, no. 1, pp. 3-14.

Kampf, G & Loffler, H 2010, Hand disinfection in hospitals-benefits and risks, Journal of the German Society of Dermatology, vol. 8, no. 12, pp. 978-983.

Lam, C, Lee, J, & Lau, L 2004, Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection, Pediatrics, vol. 114, no. 5, pp. e565-71.

Mani, A, Shubangi, A M & Saini, R 2010, Hand hygiene among healthcare workers, Indian Journal of Dental Research, vol. 1, pp. 115-118.

Maxfield, D & Dull, D 2011, Influencing hand hygiene at spectrum health, Physician Executive Journal, vol. 37, no. 3, pp. 30-34.

Nazarko, L 2009, Potential pitfalls in adherence to hand washing in the community, British Journal of Community Nursing, vol. 14, no. 2, pp. 64-68.

Ott, M & French, R 2009, Hand hygiene compliance among healthcare staff and student nurses in a mental health setting, Mental Health Nursing, vol. 30, pp. 702-704.

Samuel, R, Almedom, A, Hagos, G, Albin, S, & Mutungi, A 2005, Promotion of handwashing as a measure of quality of care and prevention of hospital- acquired infections in Eritrea: The Keren study, African Health Sciences, vol. 5, no. 1, pp. 413.

The practice-based nursing theory was used for this report. It has provided the necessary framework for the process of planning a nursing intervention. It was favored over more abstract theories because it had a more direct effect on nursing practice. For instance, Jean Watson, a nursing theorist, has identified hand-washing as a time to center, reflect, empty, and consciously remind oneself of the importance of quieting and slowing down, allowing authentic presence to emerge (as cited in Mick, 2016, p. 1759). Although practice-based theories are connected to the concepts from middle-range and grand theories, they remain narrow in scope.

The paper proposes an implementation plan to improve hand hygiene compliance in hospital settings, particularly in neonatal care units. Based on the research examined earlier, there is a need to develop a self-assessment form for nurses. Firstly, successful implementation requires management support, which is why the senior nursing staff has to be informed about the changes using multiple communication channels (World Health Organization, n.d.). Then, a chief nursing officer (or another nursing supervisor) should appoint a coordinator or a multi-disciplinary team that would be in charge of hand hygiene improvement (World Health Organization, n.d.). Lastly, hospitals will need to identify existing hand hygiene policies and guidelines and align them with the new plan. To ensure systematic change, there is a need for the baseline assessment of resources by each hospital (World Health Organization, n.d.). Then, hospital executives need to ensure the procurement of hand hygiene products, including towels, water, soaps, hand-rubs, and sinks. Senior nursing staff and program coordinators have to obtain financial resources from superiors to facilitate the effective implementation of the hand hygiene improvement initiative.

After the first steps, there is training and education. They involve numerous activities, but most of all, planning. The staff needs to identify skilled trainers and allocate the appropriate portion of the hospitals budget for their employment. These professionals would partake in the process of designing a basic hand hygiene education program. Apart from teaching classes, they would also develop a plan for continuous education based on the feedback. The next step in the implementation would be ensuring there are enough reminders for nurses. This can be done through various online and offline distribution materials. The implementation would follow a multimodal approach by having a system of periodic self-assessment. The program would be constantly evolving based on its evaluations and nurses feedback. The last step would include community and patient engagement through a series of events, discussions, and entertainments. The outcome measures in this implementation model include rates of HAIs. Therefore, the use of these rates over time will indicate the success of the program. HAI rates will also help to assess the impact of the program on the quality of care and patient satisfaction rates. The program will be identified as successful if there is an increase in hand hygiene compliance, in the utilization of hand hygiene products, and in the improvement of hand hygiene.

The implementation of the proposed hand hygiene program is by the evidence-based practice (EBP) guidelines. EBP is essential to providing quality care to patients because it is an integral part of enhancing the nursing practice. Adopting EBP improves patient outcomes and increases healthcare provider satisfaction rates (Mathieson et al., 2019). The report features a PICOT, which is s a four-part method of developing a question that would assess the problem, intervention, comparison, outcome, and timing. The question is Can hospital-acquired infections (P) be effectively minimized by proper hand hygiene compliance (I) practiced by care providers compared to non-compliance with hand hygiene practices (C) in as far as improvement of patient outcome and care quality is concerned (O) within five months (T)? Additionally, a detailed literature review is included in the report. It consists of various critiques of the latest academic research regarding hand hygiene and HAIs. Therefore, it is evident that the report has used a series of data-guided investigations to generate the most definitive conclusions. As a result, an implementation plan was developed.

Evaluation is another important part of the hand hygiene program implementation. The process will include regular evaluation and feedback. Regular evaluation refers to setting up hand hygiene compliance observations over time. Hospital staff and program coordinators would identify the sources of expertise for the evaluation process, including data managers and epidemiologists. The feedback portion will imply the creation of a specific system that will allow coordinators to record and report results to senior staff in the most time- and cost-efficient way. Feedback will also facilitate open communication and further development of the program. Prioritizing evaluation is important to make appropriate changes to the program and optimize the training process. There are several potential barriers to the implementation of the program. Firstly, there is currently a lack of agreement on what optimal hand hygiene compliance should be for a specific clinical setting or situation (Gould et al., 2017). Secondly, there is very little accessible data regarding the cost-effectiveness of hygiene initiatives, which is a major challenge for the programs implementation in a bureaucratic hospital setting.

References

Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., & Taljaard, M. (2017). Interventions to improve hand hygiene compliance in patient care. Cochrane Database of Systematic Reviews. Web.

Mathieson, A., Grande, G., & Luker, K. (2019). Strategies, facilitators and barriers to implementation of evidence-based practice in community nursing: a systematic mixed-studies review and qualitative synthesis. Primary health care research & development, 20(6). Web.

Mick, J. (2016). An alternative to singing Happy Birthday: Healthcare providers rhyme for handwashing time. American Journal of Infection Control, 44(12), 1759-1760. Web.

World Health Organization (n.d.). Template action plan for WHO framework. Web.

Sunkesula, V. C., Kundrapu, S., Knighton, S., Cadnum, J. L., & Donskey, C. J. (2017). A randomized trial to determine the impact of an educational patient hand-hygiene intervention on contamination of hospitalized patients hands with healthcare-associated pathogens. Infection Control & Hospital Epidemiology, 38(5), 595-597. Web.

The authors conducted a quantitative randomized trial (non-blinded) to identify a possible effect of a specific educational hand-hygiene intervention on the spread of healthcare-associated bacteria and viruses. Sunkesula et al. (2017) focused on testing the hypothesis on whether the hand-hygiene intervention could contribute to reducing the contamination of patients hands with pathogens. The sample included 95 newly admitted patients, among those only one participant was a female. The median age was 62 years, and patients with dementia or limited possibilities to conduct hand hygiene were excluded from the sample. The study was conducted in Cleveland, Ohio, based on the setting of Cleveland Veterans Affairs Medical Center. This center is a 210-bed facility providing acute care services. The researchers implemented an educational hand-hygiene intervention for patients in contrast to providing hand sanitizers (Sunkesula et al., 2017). They found that, in those patients following the intervention, the amount of pathogen culture on hands significantly reduced in comparison to the control group.

Ay, P., Teker, A. G., Hidiroglu, S., Tepe, P., Surmen, A., Sili, U., Korten, V., & Karavus, M. (2019). A qualitative study of hand hygiene compliance among health care workers in intensive care units. The Journal of Infection in Developing Countries, 13(2), 111-117. Web.

The researchers conducted a qualitative study based on focus group discussions and interviews. Ay et al. (2019) were interested in addressing the research question of why poor hand hygiene adherence could be observed among healthcare providers in intensive care units. The sample of the research included 25 participants performing the roles of nurses, physicians, administrators, and interns in the chosen facility. They were involved in focus group sessions and interviews organized to address the principles of the Theory of Planned Behavior (Betz et al., 2018; Schmidt & Brown, 2019). The participants were selected to provide as many opinions on the issue as possible. The setting of the study was a teaching hospital located in Istanbul, Turkey. The authors found that healthcare providers and administrators followed hand hygiene referring to the emotional factor and their personal views regarding dirtiness. Therefore, the researchers concluded on the necessity of training for nurses and physicians, along with other healthcare professionals, to guarantee they follow the rules and policies on hand hygiene in a hospital.

References

Betz, C. L., Krajicek, M. J., & Craft-Rosenberg, M. (Eds.). (2018). Guidelines for nursing excellence in the care of children, youth, and families (2^nd ed.). Springer Publishing Company.

Schmidt, N. A., & Brown, J. M. (2019). Evidence-based practice for nurses: Appraisal and application of research (4^th ed.). Jones & Bartlett Learning.

Infections acquired in the hospital are currently one of the major causes of mortality and morbidity. Proper hand hygiene practices, in turn, are considered to be an effective way to prevent the transmission of infections during communication and interaction between patients and medical staff. Despite the fact that health professionals are aware of the importance of hand hygiene, compliance levels remain low in many facilities, including the organization in question. Since Novant Health is one of the facilities where patients length of stay is on average longer, ensuring proper hand hygiene compliance is essential to reduce hospital-acquired infections and other negative consequences (Novant Health, n.d.). Investing in the new technology aimed at improving hand hygiene compliance will therefore allow the board to prevent numerous health consequences that are dangerous both for patients and clinicians working in the given facility. In turn, lack of sufficient investment in this technology may cause health workers negligence and poor motivation to practice hang hygiene, which will lead to the transmission of germs, including antibiotic-resistant microorganisms. Thus, new process changes need to be introduced to ensure higher levels of hand hygiene compliance.

The Impact of the Change

Specific recommendations suggested as a part of this proposal will include the introduction of the Hand Hygiene Compliance Application, which will help health professionals to monitor and improve their hand hygiene compliance. The design and the functionality of the app will be developed in a way that will ensure that users are provided with the most convenient way to report and monitor their compliance rates. In addition, health professionals will need to be consulted on the importance of using the app and how it will affect the overall performance rates of their facility. These specific recommendations should currently be a priority because they will allow to direct the boards attention towards those areas of the facilitys operations that need to be targeted. Most importantly, this change will ensure that the organization acts according to its mission to improve the health of communities, one person at a time (Novant Health, n.d., par. 2). Since the main concern associated with poor hand hygiene compliance is patients health and well-being, following the recommendations presented will have a significant positive impact on the organizations ability to meet its mission.

In addition, the organization will be able to have return on investment as a result of introducing and investing in this change. This is mainly due to the fact that improved hand hygiene compliance will reduce the prevalence of hospital-associated infections, and the number of patients that have to be treated from them will decrease. Consequently, the organization will also be able to have greater efficiency and lower operational costs. Another important advantage for Novant Health as a non-for-profit organization is the opportunity to do social or public good.

Planning a Process Change

To plan for a process change aimed at improving hand hygiene (HH) compliance, the task force would use the PDSA model, data collection, process mapping, and process analysis tools, such as flowcharts and diagrams. The PDSA model will allow creating a step-by-step plan for the improvements by implementing a trial-and-learning method and evaluating changes in a time-efficient manner (Gould et al., 2017). Data collection tools that will be used include a standard HH observation form, WHOs Data Collection Tool, and a researcher-made HH questionnaire (Alper, 2021). This data will then be statistically analyzed using process analysis tools and techniques, such as Paired-samples T-test and Chi-squared test (Gould et al., 2017). Process mapping will be used to create a detailed visualization of the process change, depicting all the individuals and parties involved in implementing and maintaining this change. The combination of these models, techniques and tools will allow documenting the process, as well as to model, analyze, and manage workflows to ensure the highest level of compliance.

Measuring Compliance

Compliance to hand hygiene practices introduced will be measured through a direct observation program which will intersect with the study phase of the PDSA model. Observers for the program will be trained on the WHOs 5 Moments for Hand Hygiene poster and WHOs Hand Hygiene Training Films (Alper, 2021, par. 4). Inner-rate reliability will also have to be assessed to ensure that observers provide consistent data. WHOs Data Collection Tool, researcher-made HH questionnaires, and a standard HH observation form will be used to conduct direct observations, after which the data will be compiled into a single database. Reports and graphs demonstrating the performance will then be created using the master database. Finally, the front-line staff will be provided with feedback, and action plans will be created for all units and departments.

Causes and Effects of Noncompliance

There is a number of reasons health professionals do not comply with hand hygiene requirements. Studies conducted in hospitals across the country have shown that healthcare workers often forget to wash their hands because they get distracted or have to enter or exit the room quickly (Clancy et al., 2021). Many professionals also feel that wearing gloves eliminates the need to wash their hands. Ineffective and insufficient education concerning safety norms in a healthcare facility is also among the most common causes of noncompliance, as are broken or inconveniently placed sinks and dispensers. Other factors contributing to the issue are skin irritation some workers have from the cleaning products and the lack of alternative products (Sands & Aunger, 2020). In addition, some workers have reported that their hands were often full with supplies, and that there was no convenient place to put them in order to wash their hands.

Even if the noncompliance issue is isolated to only a few staff, it poses certain risks for the improvement process. If some healthcare workers demonstrate poor hand hygiene compliance, patients safety will remain jeopardized due to the spread of hospital-acquired infections, posing threats to all people admitted and discharged from the hospital. Moreover, non-compliance practices are likely to become more widespread, compromising the safety of other workers and patients.

Additional Recourses

To develop a hand-hygiene procedure, the taskforce may need additional resources and information. First, the researchers and observers will have to study the strategies and interventions recommended by the World Health Organizations concerning hand hygiene compliance (Alper, 2021). Electronic Message Boards will also be required to provide workers with the means to receive daily reminders, updates, and other information (Sands & Aunger, 2020). In addition, different types of signage, such as flyers and posters will have to be posted in various places, such as bathrooms, nurses rooms, hand sanitizing stations, etc.

Ensuring Compliance

Compliance can be ensured through regular discussions held for the workers to gain their feedback and self-reflections regarding the implementation of the change. Health professionals will be asked to share their experiences and thoughts, assessing their own compliance with hand hygiene requirements. The observers will also be asked to share their conclusions, and different viewpoints can be compared in order to gain a broader understanding of the issue. This will also allow the taskforce to analyze the change implementation and introduce necessary modifications at any given stage of the process (Sands & Aunger, 2020). In addition, the taskforce can install more hand-washing stations and sanitizers, as well as tables and other surfaces for supplies, which will make it easier for workers to wash hands more often.

Conclusion

The planning and implementation processes described above allow the conclusion that this change would be highly beneficial for Novant Health, as it will focus on one of the organizations main problems. It can be argued that the initiatives presented align with the organizations strengths, such as focus on patient care and financial stability. These factors will provide the organization with opportunities and resources to successfully introduce the change. Despite the organizations strengths, relatively low hang hygiene compliance rates are still its major weakness, which will, however, directly be influenced by this initiative. To ensure successful implementation of the change, staff will have to undergo a short training program aimed to develop skills for the successful use of the new technology. No additional competencies will be needed within the staff of Novant Health. New organizational capability that might be required to use this technology effectively is a team of qualified specialists in computer programming and design engineering to develop and maintain different aspects of the technology introduced.

References

Alper, P. (2021). Best practices for measuring hand hygiene compliance. Medline. Web.

Clancy, C., Delungahawatta, T., & Dunne, C. (2021). Hand-hygiene-related clinical trials reported between 2014 and 2020: A comprehensive systematic review. Journal of Hospital Infection, 111, 6-26. Web.

Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., & Taljaard, M. (2017). Interventions to improve hand hygiene compliance in patient care. Cochrane Database of Systematic Reviews, 17(9). Web.

Novant Health. (n.d.). The mission that drives us and the values that guide us. Web.

Sands, M., & Aunger, R. (2020). Determinants of hand hygiene compliance among nurses in US hospitals: A formative research study. PLOS ONE, 15(4), e0230573. Web.

Among many other dental hygiene application essay examples, this one is a must-read. The following dental hygiene essay will give several arguments on why you might want to be a dental hygienist over anything else. The author will talk about their childhood and skills and say a few words about the obligations of a dental hygienist. Read the sample and write your own Why I Want to Be a Dental Hygienist Essay.

It may not be such an easy task to choose a career to pursue, as one may like to believe. Some people have taken a long time to realize their desired professions. Others recognize their early life potential and make their career choices instantly. For a variety of compelling reasons, I have decided to pursue a career in dental hygiene.

I used to eat a lot of sugary food when I was about ten years old without realizing how much harm was done to my teeth. It wasnt long before my first premolar tooth began to hurt. The misery and anguish that I had to endure before removing it were intolerable. This experience inspired me to start helping others to improve their oral health.

Since then, I have always wanted to work in dental hygiene. I wished to provide people with qualified preventive care. At the same time, I understood the trouble doctors and their dental patients went through. Ive prepared myself for a challenging mission of becoming an advocate for personal dental hygiene across the country.

As you may know, being a dental hygienist can be a very challenging task. However, I am confident that I have all of the required skills. I am open-minded, attentive to detail, compassionate, and committed. Moreover, in a stressful situation, I will be ready to act with zero uncertainty. My goal is to have nothing less than perfect results in all my future endeavors.

Once it comes to sensitizing people about the risks of bad oral hygiene, my skills will become essential. The oral cavity is one of the most sensitive regions. So, dealing with patients requires a great deal of accuracy. I can also create an informal and friendly atmosphere for any client so that they can feel comfortable.

Over the past few years, the need to promote dental care has increased. It especially concerns the prevention of various oral infections. As a consequence, this puts a lot of stress on dentists who have to look after the increasing number of patients. While dentists are often concerned with technical procedures, dental hygienist services are required to provide preventive care. That is, among other responsibilities that aid in the treatment of patients with dental problems.

I can think of several main duties of a dental hygienist that I can skillfully perform. Several of the essential tasks include brushing and polishing the teeth of customers, as well as flossing them. Sealing the teeth of patients to avoid cavities is also a critical duty. Another task is to consult the clients. A dental hygienist should keep them updated about how to improve dental health and resolve any occurring issues.

A dental assistant must take and analyze X-rays until a dentist evaluates the anatomy of the teeth for new treatment procedures. Dental hygienists are accountable for devising the patients report cards. A dental hygienists job includes assisting the dentists. They are responsible for dental care procedures that are more complicated and require additional experience. For example, a fluoride varnish must be done by the dentist.

I would like to faithfully represent the society once I have earned the first accreditation as a dental hygienist. I desire to improve in the profession. So, I will surely pursue further studies in this area to reach a masters degree. This goal is set for my long-term vision of working in public institutions, such as dental schools, hospitals, research centers. I even consider working as a hygiene coordinator in a dental clinic.

FAQ

How to start a dental hygiene written essay?

An excellent way to start a dental hygiene essay is like any other personal statement or a recommendation letter. Begin with a short sentence explaining your interest in the topic. It will help to capture the readers attention.

What are the benefits of being a dental hygienist?

There are many good reasons to work as a dental hygienist. Due to ever-increasing population numbers, such jobs will remain in high demand for a long time. Youll have a flexible schedule and a satisfying salary. Most notably, you can help improve peoples health and lives.

How do I write an essay on dental hygiene?

Start with an introduction and mention the reason for your interest in the profession. List your qualities that will be useful in the area of dental hygiene. Talk about the duties of a dental hygienist. In your conclusion, summarize your key points and write about your future career plans.

What does it mean to be a dental hygienist?

Its when you have the right qualifications and knowledge about dental medicine. The ability to apply this expertise in your field of work is also significant. Above all, being a dental hygienist means that you should always be ready to help those with a problem.

What should an oral hygiene essay be about?

An oral hygiene essay should be about the practices of maintaining your oral hygiene. It would help if you also elaborated on the dangers of neglecting it. Be sure to make it interesting and thought-provoking for the reader.

What to include in a why I want to be a dental hygienist essay?

The good idea is to include your personal story. Talk about why you want to become a dental hygienist, express your passion for this career. Also, do not forget to list the skills that you think will help you in the profession.

In nursing and other professions, evidence has shown that hand hygiene is highly important. Hand hygiene has helped reduce the spread of bacteria and infection. The World Health Organisation (WHO) has made a standardised step by step process that is known across the whole world. Hand hygiene can prevent most healthcare-associated infections if health professional wash their hands at the right moments.

Evidence-based practice, what is it? Evidence-based practice is used to find the best research in health interventions, best practise intervention provides our patients with high quality care in a safe manner. Ongoing studies provide researchers with evidence on what is best practice.

Each year, 180,000 patients are affected by healthcare-associated infection (HCAIs) all around the world. (Allegranz, 2011) Our solution to this problem is practising great hand hygiene throughout the care of patients, doing so by using the correct method and right moments of hand hygiene. These 5 moments of hand hygiene include; before touching a patient, before procures, after body fluid exposure, after touching a patient and after touching a patient’s surroundings. (About SAVE LIVES: Clean Your Hands, 2009) This approach was designed to be simple, easy to learn, applicable in any setting and effective. It was created to enable health professional with a natural workflow

With all the knowledge that has been provided to health professionals, are these techniques being performed correctly? is hand hygiene being compromised in an area such as the emergency departments compared to a general ward? This question is being asked as emergency departments easily fill up quickly. Nurses and other health professionals in an emergency department are more than likely to be placed in a situation where they must act in a fast and timely manner. These emergencies could include conditions that have been suspected serious to requires acute schedule care. (Healthcare Associated Infection, 2018)

Research question

Is health professionals, effective in their hand hygiene in an emergency department, compared to a general ward being compromised?

In PICO Form

• P – Is health professionals,
• I – Effective in hand hygiene in emergency departments
• C – Compared to a general ward
• O – Being compromised.

This question will help determined whether hand hygiene techniques are being held even when placed in a stressful situation. This question is a prevention type of question as to the research data will enable health professional to revaluate their effort in performing the hand hygiene technique. Poor hand hygiene can cause bacteria to be transferred to a patient which causes hospital-acquired infection. This question aims to find out if health professionals are performing the technique adequately compared to a general ward. Less hospital-acquired infection means the patient is discharged in the appropriate time for their condition and less money is spent on hospital-associated infections.

Format to search my question

Using keywords within my question, I’m going to search with databases such as; clinical key, cinahl and the USQ Library. The keywords involved are Hand Hygiene and Emergency departments. I will then filter the journals by specifying what publish dates I’m looking for. When searching through a journal article, I will be looking at the title and the abstract, seeing if that is relevant to my question and then move on to the introduction. if I see that the paper isn’t relevant ill put it down and search for new paper. I will continue this method to find relevant research for my question. (Checklist for Systematic Reviews and Research Syntheses, 2017) The limitation will be placed on the publication date to be within the last 10 years.

Once finding my journals articles, I will be using the Joanna Briggs Institute. The appraisals to assess the methodological quality of a study, it used to check for the possibility of bias within the design, conduct and analysis.

My 5 research articles include;

1. Keep it clean: a visual approach to reinforce hand hygiene compliance in the emergency department. This journal article is quantitative research, on the hierarchy this journal article fits into experimental studies level 1.b systematic review of randomized controlled trials and other study designs.
2. The development of hand hygiene compliance imperatives in an emergency department. The journal article is quantitative Research. On the hierarchy, this journal article fits into Observational analytical studies level 3.a
3. Hand and Hygiene Compliance in an Emergency Department: The Effect of Crowding. This journal article is quantitative research, on the hierarchy, this journal article fits into experimental studies level 1.a systematic review of randomized controlled trials.
4. Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department. This journal article is qualitative research, on the hierarchy, this journal article fits into experimental studies level 1.a systematic review of randomized controlled trials.
5. Interventions to improve hand hygiene compliance in emergency departments: a systematic review. This journal article is quantitative research, on the hierarchy, this journal article fits into Observational analytic studies 4.b systematic review cross-sectional study.

Reviewing and synthesizing the evidence

It is highly important to critically appraise when looking for evidence of best practice, the data within the journal article may be bias or perhaps the limitations don’t provide an accurate result. This may be because participant either dropped out of the study or they were not contactable. Is the article clear and concise? Critical appraising can help the reader to help identify whether it is reliable.

Why were these journal articles chosen? These articles were chosen as they had a research that involved information relating to emergency departments and hand hygiene. Research information on general wards hygiene competency was very limited. Although these articles have discussed briefly that the emergency department hand hygiene was considerably low compared to other wards. This is mainly due to the busy demand within the department, as well as the limited spacing. These articles are all within the last 10 years. They share the same core point of poor hand hygiene has an impact on patient’s safety and may prolong their stay. Hand hygiene compliance by health professional sits at only 40% according to the article Hand Hygiene Compliance in an Emergency Department: The Effect of Crowding Despite. (Muller, Carter, Siddiqui & Larson, 2015) These articles will enable me to formulate an answer to my research question, as each journal article has been thoroughly reviewed and provides a statistic of their research.

Synthesis of the five articles – the body of evidence

Throughout all five journals article, they all had one factor that was the same, all articles discussed lower percentages of hand hygiene being followed in the emergency department. The articles discussed the factors that are contributing to these low percentages, these include; medical emergency, heavy workloads, lack of time, poor work culture, higher patients load, limiting requirement, not knowing when to wash hands and improper technique of hand hygiene. (Jeanes, Coen, Drey & Gould, 2018) (Muller, Carter, Siddiqui & Larson, 2015) Each article introduced a program in aim to improve the compliance of performing correct hand hygiene within the emergency department. In turn, this would decrease the risk of hospital-associated infection and improve patient safety. The lower hospital-associated infections mean lower prolonged hospital visits and health care cost reduced. Each study had their strength and weakness based on their research methods however, all interventions had an impact on the staff’s hand hygiene overall compliance. These journals articles were unfortunately not Australian data, the search engines were very limited to finding Australian research.

The article named the development of hand hygiene compliance imperatives in an emergency department designed a program that allows health professionals to analyse a barrier of hand hygiene, as a team and plan of action to overcome this barrier. This resulted in positive work culture. Health professionals were more likely to action a plan to overcome a barrier within their workday. (Jeanes, Coen, Drey & Gould, 2018)

The article Interventions to improve hand hygiene compliance in emergency departments: a systematic review aimed to investigate hand hygiene compliance, they wanted to identify factors that contribute to poor hand hygiene. They did this by researching previous research study on this topic and compared the data. (Seo et al., 2019)

Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department. Aimed to assess the effects of multimodal hand hygiene strategy. They provided health professionals with education and continuous reminders around the ward, such as having computer screens as the 5 moments of the hand hygiene logo. An undercover nurse would also comment on rings to encourage health professional to follow procedures. These interventions resulted in compliance rising each week after education was given. (Arntz et al., 2016)

The article Hand Hygiene Compliance in an Emergency Department: The Effect of Crowding, aimed to see how overcrowding of patients affected hand hygiene, this was done by observing a sink bay for 20 minutes throughout Monday to Friday. Out of the 116 observed hand hygiene opportunities resulted in mean compliance of 29% and alcohol base of 66%. Overcrowding was associated with poorer hand hygiene. (Muller, Carter, Siddiqui & Larson, 2015)

Although these articles have great research results within, the article that best supports my research question is Keep it clean: a visual approach to reinforce hand hygiene compliance in the emergency department. This journal article implemented a visual way to identify poor hand hygiene, done within the emergency department. Participants used a glowing agent before performing hand hygiene, once hand hygiene had been performed participants were asked to place their hands under a ultraviolet light to highlight areas that were missed. The glowing agent was later found on keyboards, computer screens and medical equipment. A meeting was held, where this evidence was shown. After all, the finding was viewed by the Emergency Department staff, hand hygiene compliance rate rose to a baseline to 70% and continued to rise 3 months after. (Wiles, Roberts & Schmidt, 2015) This information helps me identify information related to my PICO question. Before this study took place, low hand hygiene practices were performed due to the heavy workload and lack of proper technique. This identifies that before having intervention placed to improve hand hygiene is poor within the emergency department.

Within these articles, they all provide strengths, weakness and limitations. Strength within them includes all the article emergency department had lower hand hygiene competency which was improved by the study designs method. They all had the overall goal to improve compliance in hand hygiene to in turn reducing the risk of hospital-associated infections. All journal articles were published within the last 10 years. However, the weakness includes not having information based within Australia, although the information is relatable. The article briefly discusses having lower infection control compared to other wards, however, there isn’t enough information. A limitation was some of the articles were only able to test the study within one emergency department. The development of hand hygiene compliance imperatives in an emergency department suggests that observing of practices help identify opportunities for areas to improve on, however, the perspective and ability of the observer may create bias and limitation based on what is seen and heard. (Jeanes, Coen, Drey & Gould, 2018) The article Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department stated that they did not count non-emergency department staff within the study (Arntz et al., 2016). Lastly, the article keeps it clean: stated that their sample was convenient, they would have like to have a larger nursing and emergency department population. (Wiles, Roberts & Schmidt, 2015)

Using the Joanna Briggs Institutes critical appraisal tool. This tool allows me to assess the article for its values, possible bias and overall appropriateness. The article is clear on what question they are asking, the journal article wanted to visually display the bacteria that can spread if poor hand hygiene is continued. The study was conducted using the 5 moments of hand hygiene that was developed by the world health organisation. The staff was given 3 research question to evaluate their knowledge and 25 questions on their baseline knowledge before using the glow agent. The researchers reinforced hand hygiene policy for those who didn’t comply with the centres for disease control. No evidence of bias throughout this article. The article has named all the authors and provides what they specialise in, the information researched within has been completely referenced. I believe this article is reputable as the article is dated, provides authors and can provide clinical hours towards Continuing professional development.

Overall emergency department hand hygiene compliances are lower than other wards. This is due to the high demand within the emergence department. Emergency departments are visited by millions of outpatients each year which means higher rates of bacteria within the department. Hand hygiene is highly important however, within the emergency department it can be delayed due to serious emergencies. Interventions to help reduce the barriers can improve effective hand washing in turn more frequent and quality moments of hand hygiene.

Introduction

Hospitals are the trusted entities for people when they are affected by serious disease conditions. However, it is an irony that hospital itself creates several complications and puts the needy in a greater dilemma. Hospital-acquired infections are one of the most common complications affecting hospital patients, in which most of them make raises the morbidity and mortality rate among patients. They include surgical site infections, urinary tract infections, pneumonia, Bloodstream infections, central line, and peripheral line-related bloodstream infections, multi-resistant organisms, Infections associated with prosthetics and implantable devices, and gastrointestinal infections. They often raise the hospital re-admission rate and thereby increase the cost of delivery of care considerably. (ACSQHC 2018) The Australian Commission on safety and quality in health care has established a standard (standard 3), which is “preventing and controlling healthcare-associated infections” aims to minimize the chances of getting preventable infections and managing them appropriately using evidence-based strategies once they have occurred. Within the sub-criteria provided, I believe “ACHIEVING MAXIMUM HAND HYGIENE COMPLIANCE” is the best possible measure to use as a tool to prevent hospital-acquired infections. Poor hand hygiene is one of the major reasons to spread of antibiotic-resistant organisms and thereby a primary cause of hospital-acquired infections. (Queensland health 2019). Thus, I believe it is worth conducting research on hospital-acquired infections and the dominance of hand hygiene in this sector. This report tries to analyse various factors related to issue, comparing the existing situation with practicable improvement opportunities and trying to find possible recommendations for a healthy health care system.

Stakeholders I need

Provision of care with the support from stakeholders benefits the health system significantly to access maximum hand hygiene compliance in preventing health care infections. Stakeholders can be both internal and external in minimising hospital acquired infections, however, strong commitment by all key stake holders s essential to achieve maximum hand hygiene compliance as there are multiple factors contribute poor hang hygiene practices. They include lack of knowledge, poor hand hygiene techniques, understaffing or overcrowding, poor access to hand washing facilities, skin conditions, and lack of institutional commitment. In achieving hand hygiene compliance, the key stakeholders’ incudes but are not limited to

1)Patients- they are extremely important stakeholders as the care provides directly affects their overall health outcome and length of stay 2) Nurses are Inevitable part of team in preventing infections 3)Physicians 4) health care leaders-Removing barriers, supply hand hygiene products to clinical areas, ensure the provision of hang hygiene posters and other educational materials. 5)Board, executives, infection control departments, auditors-Setting up of goals and expected outcomes, Auditing and other quality measurement initiatives, identify areas to improve. (Hand hygiene today 2006)

The others stakeholders can be unit techs, medical assistants, respiratory therapists, social workers, dietitians, physical therapists, pharmacists, and environmental technicians, microbiologists, administrative staff as they have frequent interactions with patients and a slight change in the hand hygiene practices can change the workflow of all of them.( Amy H et al 2018) Stakeholders Involved in the selection and installation of hand hygiene products are also relevant to ensure maximum output. Housekeeping also plays a vital role in preventing hand hygiene practices by timely refilling of hand hygiene products, dispose and manage leftover stock and garbage disposal. (Amirov C et al 2017). The more experts involved, the better will be the outcome. Each of them will be an expert in their profession. (Van Limburg M et al. “Managing stakeholders needs” and “quality communication with stakeholders” are essential while coordinating care with them. (OSSIE toolkit 2010)

Pest influence

It is worth analysing the issue based on “PEST”; political, economic, social and technological pressures on these nosocomial infections. While considering political pressures on hospital-acquired infections, funding from the government is a vital component. There would be a colossal demand for funding with the outburst of infections in a hospital facility and the unavailability of these funds would create serious laps in the quality and safety of patient care from the particular organization. (Dalzell S 2019) However, there is a recent initiative from commonwealth government Australia, which is withholding the payment to hospitals where patients have avoidable complications; aims to improve the quality of care and to reduce the cost of delivery of care. The hospital will be funded on an activity-based system, means receive money for the service they deliver. (Dickinson H 2017). However, hand hygiene is considered the most successful and cost-effective strategy which can be adopted.

The below-mentioned data enlightens how governments are benefitted adopting hand hygiene as a preventive strategy for hospital-acquired SAB infections. (Graves N et al 2016)

Economic pressures on hospital-acquired infections are another crucial concern require much attention. It is evident from the researches that people especially those who are non-citizens and with no insurance support ending up with greater financial burdens from out of pocket payments for the additional diagnostic tests, treatments, number of days in the hospital, and post-discharge complications due to these nosocomial infections. (Y. Mo et al 2019)

The below graphical representation clearly represents the increase in the cost of care as a result of hospital-acquired infections in Australia (pricing framework for Australian public hospital services).o

A Hand hygiene program conducted by the University of North Carolina hospital in the USA reveals the relevant data showcase the significance of hand hygiene to ease health care infections. (Sickbert-Bennet e et al 2016).

Comparing these two studies clearly defines the significance of hand hygiene in reducing the economic burden created by healthcare-associated infections.

Studies have also identified some social challenges due to these infections and hospital stays. Even though some people demand, strengthening their family bond due to frequent visits during the hospital stay, it is also apparent that there are disharmonies among family members due to the hospital bills, responsibilities of family members during hospitalization. Patients are also in need of multi-disciplinary approach which includes services from social workers, psychologists, emotional and financial support to enable complete recovery from post-traumatic stress as a result of extended hospital stay. (Y. Mo et al 2019). Following proper hand hygiene practices can ease the prevalence of healthcare infections and in turn, reduces the length of hospital stay.

While taking technological pressures into consideration, unsuitable isolation design, poor facility ventilation, ineffective triaging, and shortage of equipment are few of the technical errors in hospitals, especially in developing countries. (Rajakurna s 2017)

In developed countries, technological advancements play a major role to ease healthcare-associated infections. However, technological innovations such as hospital-owned tablets and iPad would act as a potential source of bacteria and would intensify the risk of patients. (Black R 2017)

Gap measurement in the healthcare organization and micro meso macro levels of analysis to resolve the issue

The major causes of health care infections include older age, poor immunity, medical conditions such as diabetes and other chronic illnesses, prolonged hospital stay, surgical and invasive procedures, inadequate hand hygiene practices, non-intact skin, Poor personal and environmental hygiene. Three levels of analysis such as micro (individuals), meso (groups within the hospital), macro (the organization as a whole) to identify the prevalent trigger in the particular organization and to resolve the issue.

Like hospitals all over the world, my health care organization is also exposed to the risk of hospital-acquired infections to a certain extend.

However, the preventive measures and strategic plan to control them show greater positive feedback to keep them under control. The policy to prevent healthcare-associated infections includes requirements for patients, staff, and visitors from acquiring preventable hospital-acquired infections, effectively managing infections if they occur using evidence-based strategies and limiting antimicrobial resistance as apart of anti-microbial stewardship. Our organisation follows seven principles;1) Governance 2) Risk and safety (Risk assessment bases on the type of procedure, health status, Clinical contacts, etc.) 3) Safe care( safe working environment through standard and transmission-based precautions, hand hygiene, aseptic technique, appropriate use of clinical devices, environmental hygiene, workforce immunisation programme4) Communication(patient-centered care, privacy, and confidentiality)5) Anti-Microbial stewardship6) Education and Training(patient and family education, staff training) 7) Compliance(Legislative compliance-public health act 2005, industry standards).

In regard to minimize these infections, my facility takes every possible initiative. Our health care facility ensures all three levels (micro, meso, macro of analysis to ensure minimizing the risk of hospital-acquired infections. Individual staff member’s infection control competencies including hand hygiene competency are assessed by unit managers (micro-level). Compliance with infection prevention and control and antimicrobial stewardship will be monitored by audits and surveillance programs by infection prevention and control committee (Meso level). Internal and external benchmarking will be performed to identify the areas of performance to be improved in the surveillance and audits (macro-level). “Environmental cleaning policy” also plays a crucial role in mitigating these infections.

However, our facility considers “HAND HYGIENE” as a simple and most effective measure to prevent hospital-acquired infections. It can be performed using either soap and water or with alcohol-based

hand rub using the proper technique (steps and duration). It is also vital to follow five moments of hand hygiene, especially in a hospital setting. The selection of the handwashing agent demand greater significance according to the situation. Patients and family members should be encouraged to participate in hand hygiene to improve the expected outcome. (ACSQHC 2020).

The below data provides a clear-cut picture of hand hygiene compliance in our hospital.

It is identified in the data that, there are missed moments especially in “before touching patients” and “after touching the patient’s surroundings”. Also, it is indispensable to note that the compliance rate is less than 85% among some health care workers such as food services, administrative staff, personal care staff and interestingly medical practitioners as well. The areas of improvement are identified which lead to the above-mentioned errors. They include improper placement of antimicrobial gel and lack of literacy regarding the 5 moments.

The process owners and stakeholders should incorporate their work to deal with the identified errors. Our organization has increased the frequency of auditing which showcased “Hawthorne effect “among our health care workers. Education and training, selection and proper installation of hand hygiene products in participation with stakeholders enabled vast improvements in hand hygiene practices. Our facility has relaunched the hand hygiene program called “Clean hands are safe hands” which covers three major areas. 1)Ongoing auditing of hand hygiene compliance (Macro and meso) 2) Auditing bare hands and arms (bare below the elbow) 3) Speaking with good judgment (Reminding people to practice hand hygiene). (Micro level).

Opportunities to improve

Concentrating more on certain areas such as opting antimicrobial hand gel as a preferred choice unless hands are visibly dirty as it has proven that alcohol-based hand rub has the broadest anti-microbial spectrum, better skin tolerability and shorter time for effective decontamination. Wearing gloves is not always protect the healthcare workers from infection, thus, hand washing should be performed at any time when indicated and after the glove’s removal. (Hand hygiene Australia). Direct observation of hand hygiene practices is a golden standard, however, controversies exist that it is a time- and resource-consuming method. Even though electronic monitoring of hand hygiene gains popularity today, researches are still in need to accept electronic monitoring as a standard due to the issues related to cost and situational awareness. (Murthy R 2018 et al). Patient participation is a potentially successful component in this area, whereas socio-cultural limitations and negative reactions of health workers would be the hindrance for effective co-operation from consumers (Alzyood M 2018 et al). Even though education and training play a vital role in improving hand hygiene practices, behavioural modification of health care workers is another key to experience quality health practices (M Pyrek 2018).

I would also like to introduce WHO’s multimodal strategic plan to improve hand hygiene compliance as it seeks immense dominance in this sector, which we can be adopted to attain successful hand hygiene compliance and thereby preventing healthcare-associated infections. Australian health system depends this strategic plan to establish improvement steps in hand hygiene compliance. Studies have proven that the key elements in this strategy would greatly suit the health system (macro-level) to achieve unprecedented outcomes in hand hygiene compliance. The five key elements include

1) System change

It includes two main areas a) Alcohol-based hand rub should be placed in all areas of point of care (example: wards, other clinical areas) or provided to staff as pocket bottles. b) Ensure access to safe and continuous water supply (one sink for every ten beds and disposable towels)

2) Training and education

Ensure all staff in the clinical setting follow the proper techniques and “five moments of hand hygiene” through training and education. It is essential to establish short, medium and long-term updating programs to ensure the quality and safety

3) Evaluation and feedback

Monitor hygiene practices and infrastructure in the frequent intervals, constructive feedback should be provided to the staff based on their knowledge and performance.

4) Reminders in the workplace

Prompting and indicating the importance of hand hygiene is vital in a clinical setting via positioning the posters. “How to” and “5 moments of hand hygiene” are in the first line in this area.

5) Institutional safety climate

Create an environment and perceptions which promotes patient safety, while guaranteeing hand hygiene improvement as a higher priority at all levels

To implement this strategy in place WHO has provided stepwise approach, they comprise

• Step1: facility preparedness – readiness for action
• Step2: baseline evaluation – establishing knowledge of the current situation
• Step3: implementation – introducing the improvement activities
• Step 4: follow-up evaluation – evaluating the implementation impact
• Step 5: ongoing planning and review cycle – developing a plan for the next 5 years (minimum)

To summarise, the below infographic image the overall expectation of this multimodal strategic plan. The organization (Macro level) plays a major role in the application of this model: however, collaboration with the other two levels such as health care leaders (Meso level) and individual staff members (Micro level) is inevitable to reap maximum expected outcome.

Overall hand-hygiene compliance in pilot sites worldwide before and after implementation of WHO’s improvement strategy by category of health professional (A) and hand-hygiene indication (B)

Anticipated benefits and potential difficulties of implementing who’s multimodel strategy

Multiple pieces of research and studies ha proven the existing and anticipated benefits of WHO’s multimodal strategy for hand hygiene compliance. Australia’s health system has adapted this strategy and modified it for the Australian environment. WHO insists on the relevance of including a range of complementary strategies instead of a single strategy to cover structural, institutional and organizational factors. Even though hospitals worldwide have accepted these initiatives, proactive steps should be taken for quality implementation by limiting flaws and errors.

When considering the barriers of implementing these strategies, there are potential consequences with a different system, resources, and cultural backgrounds. Risk of resistance to change, scarcity of continuous resources for sustainability, cultural and religious barriers for adoption, scale-up, and maintenance. (Allegranzi B 2013). It is also noticed, implementation of isolated elements such as a change in the infrastructure and distribution of educational posters does not guarantee the successful hand hygiene compliance whereas, strong commitment and involvement of management with security actions, constructive feedback with active and permanent methodologies for education are essential to ascertain sustainability in the implemented strategy (Valim M D 2019et al).

All the other aspects mentioned above for the “opportunities to improve” should also be monitored and implemented appropriately for the effectiveness of strategic plans in hospitals.

Recommendations

In our current scenario of COVID 19, we all have acknowledged the pertinence of maintaining hand hygiene in our day to day life and we should be more sensible when it comes to hospital ambiance. In ACSQHC standard 3, there are several other criteria along with hand hygiene that should be considered while aiming to prevent healthcare-associated infections. Effective hand hygiene practices work hand in hand with all other infection control measures such as antimicrobial stewardship, aseptic techniques, invasive medical devices, clean environment and so on. Healthcare organizations should develop necessary initiatives to review a list of accepted strategies and apply them to the clinical practice of an individual health worker as well as institutional supportive measures to encompass overall hospital-acquired infection efforts.

1.0 Introduction

Barone (2019) define quality management (QM) as “the act of overseeing all activities and tasks needed to maintain desired level of excellence”. Association for Project Management (2019), further explains that QM consist of four elements which are quality planning, quality assurance, quality control and quality improvement. The focus in this discussion is on quality improvement (QI). QI is a systemic approach by employees in an organization to analyse the process for continuous improvement in the quality of the product and sustained.

The dynamic approach of the healthcare industry in prioritising quality improvement is a valuable initiative in advocating the safety of the customers receiving treatment. The Institute of Medicine (IOM) committee on Quality of Health in America revealed a finding done in 1999 entitled “To Err is Human: Building a Safer Health System” that the number of death due to medical error in American hospitals yearly is between 44000 and 98000 and over one million injuries (Wakefield, 2000; Stelfox, Palmisani, Scurlock, Orav, & Bates, 2006). These numbers are alarming as the rate of death is high compared to high risk industries such as the aviation industry. Following this report, it became an eye opener for researches to conduct research and published article pertaining to safety in healthcare and triggers the health industry to improve quality and focus on patient safety.

Today, many healthcare organisations are competing to be certified under various accreditation bodies to ensure the treatment and high quality service rendered to the community are safe and of excellent quality. This indirectly boosts their business income and gain the trust from their customers who are particular with high quality standards. The organizations are being audited by various reputable accreditation bodies such as Malaysian Society for Quality in Health (MSQH), International Organization for Standardization (ISO) or Joint Commission International (JCI).

2.0 Quality improvement in healthcare system

According to the United States (US) Department of Health and Human Services Health Resources and Services Administration [HRSA] (2011), quality improvement (QI) “consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups”. In Malaysia, quality improvement in the healthcare sector has been the top most priority in the public and private sector. The initiative on continuous QI of the healthcare in the public sector is also supported by the Ministry of Health. Health Minister, Dr Dzulkefly Ahmad announced that the ministry is looking into improving the quality of the health care at public sector by implementing six measures which highlight on upgrading the facilities, improving waiting time as well as alliance between public hospital and local universities. Last but not least is to collaborate specialist and non-specialist hospital to reach out to the public living in the rural area (Bernama, 2018).

Hidayah (2015) reported in the Malaysian Medical Gazettes on the seven strategies taken by the Ministry of Health (MOH) in Malaysia on patient safety. The initial stage was establishing specific organizational structure such as Patient Safety Council. The next step is to maintain good networking and collaborations with organization such as World Health Organization (WHO) and International Safety for Quality in Healthcare (ISQUA). Followed by producing policies and guideline in the aspect of patient safety, ongoing training to healthcare staff and public to increase the awareness on safety. The subsequent step is to implement a national monitoring system on patient safety, which is Malaysian Patient Safety Goal as a portal for the public as well as private sectors to send their respective data annually as a form of benchmarking nationwide. The next strategy is to conduct research pertaining to patient safety and translate the findings into national policy such as the Lab Critical Value Programme and finally to have programmes on patient safety which is the 13 Malaysian Patient Safety Goals which was launched in 2013 as shown in Figure 1.

Figure 1: 13 Malaysian Patient Safety Goals. Source: https://slideplayer.com/slide/7931695/

QI programs are essential in healthcare setting in improving outcomes for patient in term of safety, reduce mortality, upgrade the efficiency of staff performance and reduce wastage due to failures in the existing process (Serino, 2019). For example, the MSQH fifth edition has around 24 standards that an organization needs to comply according to the services available in the organization. Overall, the QI programs should focus on patient-centered, safety, effectiveness, efficient, equitable and timely (The Scottish Government, 2010). The working committee of Quality Management System (QMS) in the organization the author works is led by the Quality Department that works diligently to guide the clinical and non-clinical department on continuous quality improvement program according to the hospital’s vision and mission. The team provides continuous training and education in QI, safety and risk management programs.

QI in healthcare defines safety events as practices that does not comply with the policies and procedure for example inserting a central line without adhering to the CVL care bundle checklist such as omitting hand hygiene prior to inserting the line. On the other hand, serious safety events are the errors that occur that can lead to harm and mortality. For example patient was transfused with a mismatched blood due to skipping a step of checking with the second nurse can lead to detrimental effect (Ministry of Health Malaysia [MOH], 2013). Near-miss event is one that almost cause harm to patient but was prevented due to the fast respond of another colleague in preventing it from happening. All this incident including near missed incident should be reported in the accident and incident (AI) for analysis and discussed in the risk management meeting to identify the preventive measure in preventing this incident from recurring. The necessary performance indicators such as the rate of compliance on hand hygiene is submitted to the relevant accreditation body to evaluate whether the changes implemented brings improvement in the organization. The implementation of hand hygiene measures focus on reducing infection to patient and staff (MSQH, 2017).

Safety of the healthcare worker and patient is paramount. There are incidents of patient or relatives who fell from a broken chair that can lead to injuries. It is necessary for the safety officer to implement measures for the head of department of the unit to identify the chairs with problem and condemn it. The Safety Officer at the author’s organization created a chair policy and data on percentage of workplace hazard is submitted monthly to MSQH via Quality Department (MSQH, 2017). The Institute of Healthcare Improvement (IHI) states that the outcome are measured to identify areas that the process could upgrade their care, identify the difference of care and show the evidence based practice that works on the interventions which is patient specific and differentiate the effectiveness of the many treatments and procedures (Tinker, 2018).

The buffer system created by carbon dioxide consists of the following three molecules in equilibrium: CO2, H2CO3-, and HCO3-. When H+ is high, HCO3- buffers the low pH. When OH- is high, H2CO3 buffers the high pH. In respiratory acidosis, the slight increase in bicarbonate serves as a buffer for the increase in H+ ions, which helps minimize the drop in pH. The increase in hydrogen ions inevitably causes the decrease in pH, which is the mechanism behind respiratory acidosis.

The buffer system created by carbon dioxide consists of the following three molecules in equilibrium: CO2, H2CO3-, and HCO3-. When H+ is high, HCO3- buffers the low pH. When OH- is high, H2CO3 buffers the high pH. In respiratory acidosis, the slight increase in bicarbonate serves as a buffer for the increase in H+ ions, which helps minimize the drop in pH. The increase in hydrogen ions inevitably causes the decrease in pH, which is the mechanism behind respiratory acidosis.

The buffer system created by carbon dioxide consists of the following three molecules in equilibrium: CO2, H2CO3-, and HCO3-. When H+ is high, HCO3- buffers the low pH. When OH- is high, H2CO3 buffers the high pH. In respiratory acidosis, the slight increase in bicarbonate serves as a buffer for the increase in H+ ions, which helps minimize the drop in pH. The increase in hydrogen ions inevitably causes the decrease in pH, which is the mechanism behind respiratory acidosis

The buffer system created by carbon dioxide consists of the following three molecules in equilibrium: CO2, H2CO3-, and HCO3-. When H+ is high, HCO3- buffers the low pH. When OH- is high, H2CO3 buffers the high pH. In respiratory acidosis, the slight increase in bicarbonate serves as a buffer for the increase in H+ ions, which helps minimize the drop in pH. The increase in hydrogen ions inevitably causes the decrease in pH, which is th

3.0 Strategies to improve the quality of care and patient safety

The author, the Head Nurse of a Surgical Unit received a report from the Quality Department that the compliance of hand hygiene in the surgical unit for the year 2018 is only 50 percent which is below the national standard of above 75 percent. Hand hygiene is the simplest and cost effective action in reducing health care-associated infection (HCAI) globally. World Health Organization [WHO] (2009) launched the “Clean Care is Safer Care” as the first Global Patient Safety Challenge which is collaborated in the 2nd KPI of Malaysian Patient Safety Goal. The practice of hand hygiene should be promoted as the best practice in reducing HCAI and improving patient safety.

The author was motivated and committed to provide good leadership in advocating and improving the compliance on hand hygiene among the staffs in the surgical unit. The QI tools that will be used is the Model for Improvement by the Institute for Healthcare Improvement (IHI) which is the plan, do, check and act cycle (PDCA) (Chen, Xie, & Liang, 2015).The author initiated by having a meeting with the all the staffs to impart the data on the hand hygiene compliance rate. All staffs are to brain storm on identifying the purpose of the non-compliance and measures to improve the compliance on hand hygiene. In the meeting, a QI subcommittee which include the link nurse was formed to identify the problem and the corrective action planned. The leader and the subcommittee identified the causes by secretly observing the practices of Hand Hygiene among the staffs according to the 5 Moments of Hand Hygiene. A root cause analysis (RCA) was done by using the cause and effect diagram which is the fishbone diagram developed by Dr Kaoru Ishikawa in 1968 (Neyestani, 2017) as shown in figure two.

Equipment/Product

Reminders

Inadequate number Empty hand soap Lack of poster

Of hand rub dispenser/paper towel

Compliance on hand hygiene

Poor location of hand rub

Lack of knowledge Lack of training

Indifference attitude No penalties for

Forgetfulness non-compliance

Lack of role model

Management

Human factor

Figure 2: Fish bone diagram on lack of hand hygiene compliance

The goal is to achieve 80 percent compliance on 5 Moments of Hand Hygiene by the nursing staff of Surgical Ward A. The World Health Organization [WHO] (2012) action plan was used as a guide to improve the compliance on hand hygiene. The second step is to look at system change by seeking the Infection Control Nurse (ICN) opinion on staff with allergic skin due to hand rub. The staff was encouraged to wash hand and soap or other option of hand rub product was given to the staff to assess for any signs of allergic. The staff with allergic skin is also advised to moisturize their hands in between completion of nursing care and to avoid using hot water to wash the hand (World Health Organization [WHO], 2009). The ICN advice to place the hand rub bottles at point of care for example at each bedside and on procedure trollies. The assistant nurse is assigned and whoever that notice the hand rub bottle is empty to replace it immediately. The cleaners are to check regularly the hand soap and paper towel dispenser and replenish accordingly.

The author and the subcommittee act as the champion to promote hand hygiene in the wards. The ICN is invited to give training on hand hygiene and emphasize the ward staffs on the importance of hand hygiene to reduce risk of Healthcare Associated Infection (HCAI). The 5 moment’s video will be shown to give a better understanding on the indication of the nurses to perform hand hygiene especially when performing aseptic procedures such as administration of medication via the parenteral route. The author and the link nurse would teach on hand hygiene step and randomly pick the staff to perform hand hygiene competency to assess the technique of washing hand to ensure optimal cleaning of the staff’s hand. The hand hygiene washing technique poster is placed on the wall above the sink as a continuous reminder (Liu, Zhang, Cheng, & Sun, 2016). The image on 5 Moments of Hand Hygiene is put as the computer screen saver and posters are placed at the patient care area and treatment room as a reminder to the nursing staff to adhere to hand hygiene. A hand hygiene corner is set up with the image of staffs acting as the ambassador of hand hygiene to motivate the staff to perform hand hygiene and to cultivate a culture of hand hygiene among the staffs. The staffs are encouraged to contribute their talent in drawing posters on hand hygiene to gain their interest in hand hygiene, promote hand hygiene culture and reward them with a token of appreciation.

Weekly meeting will be done to provide feedback to the staffs on the compliance observation done by the subcommittee and the head nurse. The moments such as before patient contact that the nurses missed to perform hand hygiene will be emphasized for improvement and sustained at high level. The head nurse and the QIA subcommittee will perform monthly hand hygiene audit according to the 5 moments of Hand Hygiene. Staffs who were found noncompliance despite given training and frequent reminders will be given counseling for the first time and verbal warning if it is the second time. The third time of violation on noncompliance in hand hygiene will affect the staff’s year end appraisal as patient safety is being ignored. Although in terms of QI, the focus is in improving the system and not blaming Lillis (2015) explained in her article that there are some study agree that some of disciplinary action is needed to stress the importance of hand hygiene.

The step by step cycle from planning right up to act gives a systematic approach in guiding the author and the team to do the necessary measures to improve compliance on hand hygiene. Implementation of the PDCA cycle, has improved the knowledge of the staff on the importance of hand hygiene, leading to increase compliance on hand hygiene. The practice of hand hygiene has been a culture in the surgical ward. The data obtained after 3 months showed the compliance of 84 percent, exceeding the target set.

4.0 Conclusion

In conclusion, QI is essential in the healthcare setting to improve the healthcare industry standard in ensuring excellence service being rendered to the public. The six main focus of QI programs are patient-centered, safety, effectiveness, efficient, equitable and timely. Quality service is for the benefit of all people including us to have trust that when we come to seek treatment in an organization, necessary standards that adhere to the legislation practice are in place to prevent harm. The activation of AI gives a direction for analysis on the incident that occur of actual incident and near missed to identify the hazard and eliminate it to prevent untoward incident to the staff and patient. As a leader, it is important to be dynamic, have an open mind and dedicated to continuously support the QI programme and work as a team to implement measures in line with the organization’s vision and mission.

5.0 Reference

1. Association for Project Management [APM]. (2019). Association for Project Management.Introduction to Quality management. Retrieved from: https://www.apm.org.uk/body-of-knowledge/delivery/quality-management/
2. Barone, A. (2019). Investopedia. Quality Management. Retrieved from: https://www.investopedia.com/terms/q/quality-management.asp
3. Bernama. (2018). New Straits Times. Six measures towards quality healthcare Retrieved from https://www.nst.com.my/news/nation/2018/06/378656/six-measures-towards-quality-healthcare
4. Chan, D. P. (2013). Orientation Program Duchess of Kent Hospital. Overview of Malaysian Patient Safety Goals. Retrieved from: https://slideplayer.com/slide/7931695/
5. Chen, C., Xie, X., & Liang, Y. (2015). Retrieved from Application of PDCA Circulation in Improving the Hand Hygiene Compliance of the Medical Staffs in Department of Burn Surgery.Retrieved from: http://www.hougner.com/wp-content/uploads/2016/07/2015-4-4.pdf
6. Hidayah. (2015). The Malaysian Medical Gazette. Retrieved July 1, 2019, from Patient Safety Must Always Be A Priority- KKM. Retrieved from: https://www.mmgazette.com/patient-safety-must-always-be-a-priority-kkm/
7. Kurowski, E. M., SchondelmeyeR, A. C., Brown, C., Dandoy, C. E., Hanke, S. J., & Cooley, H. L. (2015). Springer Link. A Practical Guide to Conducting Quality Improvement in the Health Care Setting.Retrieved from: https://link.springer.com/article/10.1007/s40746-015-0027-3
8. Lillis, K. (2015). Infection Control Today. Hospital Managers Can Help Drive Hand Hygiene Compliance. Retrieved from: https://www.infectioncontroltoday.com/hand-hygiene/hospital-managers-can-help-drive-hand-hygiene-compliance
9. Liu, Y. H., Zhang, L., Cheng, K., & Sun, X. (2016). Acta Medica Mediterranea. Application Of PDCA Cycle in the Management Of Medical Staff Hand Hygiene in Community Hospitals. Retrieved from: http://www.actamedicamediterranea.com/archive/2016/special-issue-1/application-of-pdca-cycle-in-the-management-of-medical-staff-hand-hygiene-in-community-hospitals/pdf
10. Ministry of Health Malaysia [MOH]. (2013). Malaysian Patient Safety Goals Guidelines on Implementations & Surveillance.Retrieved from: http://patientsafety.moh.gov.my/v2/?page_id=60
11. MSQH. (2017). MSQH 5th Edition Hospital Accreditation Performance Indicators Standard. Retrieved from: https://www.msqh.com.my/home/downloads
12. Neyestani, B. (2017). Munich Personal RePEc Archive. doi:https://doi.org/10.5281/zenodo.400832
13. Serino, A. (2019). Clear Point Strategy. 5 Examples Of Quality Improvement In Healthcare & Hospitals.Retrieved from: https://www.clearpointstrategy.com/examples-of-quality-improvement-in-healthcare/
14. Stelfox, H. T., Palmisani, S., Scurlock, C., Orav, E. J., & Bates, D. W. (2006). National Center for Biotechnology Information (NCBI). The “To Err is Human” report and the patient safety literature. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464859/
15. The Scottish Government. (2010). Scottish Government. The Healthcare Quality Strategy for NHSScotland. Retrieved from: https://www.gov.scot/publications/healthcare-quality-strategy-nhsscotland/pages/2/
16. Tinker, A. (2018). Health Catalyst. The Top Seven Healthcare Outcome Measures and Three Measurement Essentials. Retrieved from: https://www.healthcatalyst.com/insights/top-7-healthcare-outcome-measures
17. U. S. Department of Health and Human Services[HRSA]. (2011). Quality Improvement. Retrieved from: https://www.hrsa.gov/sites/default/files/quality/toolbox/508pdfs/qualityimprovement.pdf
18. Wakefield, M. (2000). American Psychological Association. doi:https://psycnet.apa.org/doi/10.1037/h0092814
19. Worcestershire Acute Hospitals NHS . (2018). Quality Improvement Strategy (Version 8) Retrieved from: https://www.worcsacute.nhs.uk/patient-information-and-leaflets/documents/2116-quality-improvement-strategy-2018-2021/file.
20. World Health Organization [WHO]. (2009). WHO Guidelines on Hand Hygiene in Health Care: A Summary. Retrieved from:https://www.who.int/gpsc/5may/tools/who_guidelines-handhygiene_summary.pdf
21. World Health Organization [WHO]. (2012). Your Action Plan for Hand Hygiene Improvement Template Action Plan for WHO Framework. Retrieved from: https://www.who.int/gpsc/5may/PSP_GPSC1_AdvancedLeadershipWeb_Feb-2012.pdf?ua=1

Abstract

Proposals talks about the importance of sanitation and personal hygiene in the field of hotel industry due to which many customers can be attracted towards the hotel. At present condition most of the people those who visited to hotel from different places are so much conscious about sanitation and good hygienic environment for spending their quality time on the basis of different research methodologies. And with the help of analysis we come to the conclusion that sanitation and food hygiene plays important role at hotel for increasing industry.

Key words: food, hospitality, hygiene, sanitation, quality

Chapter – 1

Introduction

1.1 Background of the Study:

Since the world business environment is changing day-to-day, we need to constantly improve and increase the productivity of Business. Since the world is shifting from manufacturing to hotel industry, we need to think about the factors that will affect the efficiency of hotel industry. Hotel business is one of the growing business across the world. It has an important impact on the economy as well as living standard of the people. Since it is one of the widely practiced business, there is high competition in the market. Without considering different factors that will contribute to the sanitation and hygiene of the hotel business. It is difficult to make our customers satisfied. So, a business need to identify the importance of sanitation and hygiene at hotel industry. “Sanitation is the maintenance of hygiene conditions through services such as garbage collection and waste disposal”- World Health Organization.

Good hygiene and sanitation are of prior importance for everyone catering to the food industry. Be it home or any star rated restaurant, the food that we eat follows a large number of steps before it reaches us. From the plantation farm to the food store-houses, then to the markets, then to the vendors and then finally to us. So sanitation and hygiene are something that need to be taken into serious consideration at each and every level be it the areas where the food is prepared, manufactured or served to be kept clean always. The first is the formal sector made up of permanent restaurants and hotels where most governmental regulations are applied. The great variety service for sale by the vendors contributes to the provision of varied diet but poor hygienic and sanitation conditions of hotels entail health risks. This may prevent inspectors from having the appropriate status and authority to implement food inspection and at the same time resist political influence and corruption at both local and national levels. An accurate hotel concept will make hotel run smoothly and customers feel comfortable. Maintaining a clean hotel environment is critical in preventing bad environment illness. Bacteria can grow on unsanitary surfaces. Just because a hotel environment looks clean does not mean that it is sanitary. Always ensure that you clean and sanitize a hotel area before and after giving service to the customer. Cleaning with soap and other detergents is just one step of the cleaning procedure. It is also necessary to sanitize. Cleaning will remove any dirt or grease, but will not necessarily kill any bacteria or other pathogens. Only a sanitizer will kill bacteria and ensure the area is safe for food preparation. Leading sanitizers used in the food service industry are chlorine solutions (bleach), quaternary solutions and iodine. Use these materials according to the manufacturer’s instructions that accompany the product and that are found on the material safety data sheet (MSDS) using the appropriate personal protective equipment. A sanitation plan is important in any food service preparation area. It ensures that all surfaces are cleaned on a regular basis and reduces the risks of transferring bacteria or other pathogens from an unclean surface to clean equipment such as cutting boards or tools. A sanitation plan has two components: A list of cleaning and sanitizing agents or supplies with instructions on their safe use and storage A cleaning schedule, outlining how each item needs to be cleaned, who is responsible, and how frequently it happens. It is imperative for safe food-handling outcomes for all workers to be familiar with standard sanitation and hygiene practices. (http://www.fnbfleet.com/blog/importance-of-hygiene-sanitation-in-hospitality-industry)

Foods should preferably be consumed immediately after preparation or held at temperature outside the danger zone which inactive or killed bacteria. The danger zone is the temperature range between 5 °C and 63°C within which most bacteria grow best.

Despite proper temperature control human contamination of food is possible, unless specific and constant hygienic practices are implemented. Healthy employees could transfer microorganisms present on or in their bodies or else they could be carrier of measure illness.

Therefore, thorough medical examination mandatory is required to declare all food handlers free from infection. Cleanliness should be the basis of all food sanitation programs and should be aimed at food protection as well as improving and maintain quality of food. The responsibility of the food service workers is to break the chain of transmission of diseases causing organisms causing organisms from carriers to food and vice-versa. This in turn would:

• a. Prevent outbreaks of food borne diseases.
• b. Reduce changes of spoilage of food.
• c. Maintain of personal hygiene and sanitation
• d. Control wastage of money and food due to spoilage.

1.2 Statement of Problem

Around the world, sanitation problems are the cause of many types of disease and death. The World Health Organization reports that problems associated with sanitation result in four percent of all deaths, and nearly six percent of all illnesses worldwide. Sanitation problems are particularly difficult for people with impaired immunity, the elderly, and the very young. Understanding sanitation problems is an important step in eliminating them.

‘Health is Wealth’- needless to say about the truth of this proverb. Health is a state of complete physical, mental, and social well being. It is not the matter to study here. In hotel industry we use the term Personal Hygiene which is most essential for every staffs and customers of the hotel industry. As per hotel terminology the meaning of hygiene is preventive, protection and destruction of harmful bacteria which contaminate in various ways. In other word one infected or contaminated by any polling or impure substance everywhere in the street. There is proverb’ prevention is better than cure’. So we can easily say that if their is problems than obviously there is solutions. (https://www.hospitality-school.com/personal-hygiene-hotel/)

1.3 Objectives of the Study:

To measure practice of Sanitation, Personal Hygiene and Hotel Environment in Hotel Industry.

Specific Objectives:

• To know the impact of sanitation on Hotel Industry.
• To know about food poisoning and food contamination in kitchen.
• To find out personal hygiene and sanitation to be followed by kitchen hygiene.

1.4 Significance of the Study

This study deals with the health and sanitation on the field of hotel industry. This study has some significance such as;

• This study helps to maintain a high standard of personal hygiene and cleanliness.
• This study helps to improves country’s image.
• This study helps to follow strict sanitation and hygiene guidance.

1.5 Limitation of the Study

Around the world, sanitation problems are the cause of many types of disease and death. The World Health Organization reports that problems associated with sanitation result in four percent of all deaths, and nearly six percent of all illnesses worldwide. Sanitation problems are particularly difficult for people with impaired immunity, the elderly, and the very young. Understanding sanitation problems is an important step in eliminating them.

The discharge of untreated waste into water systems is one of the most common sanitation problems. This creates multiple issues, such as polluting drinking water, creating a breeding ground for insects that spread disease, and exposing bathers to infectious disease. Contaminating the water sources also has an indirect affect on health by exposing foods, such as vegetables and fish, to the pathogens present in contaminated water. Not only does this contaminate the food supply, but it also reduces the amount of food available.

Contaminated wells are another sanitation problem. In areas that rely on hand dug wells, the typically shallow depth of the wells often allows for contamination from the groundwater. The overcrowded living conditions and the improper disposal of waste result in contaminated groundwater.

1.6 Chapter Plan:

The thesis will be divided into five chapters excluding preliminary sections and Appendix. The preliminary section will include title page, approval page, acknowledgement, table of contents, list of tables and figures, acronyms and abstract. The research is divided into different parts. The last part includes references.

1.6.1 Introduction

Chapter one includes the background of the study and introduction of the study area. The chapter also includes the research problem, objectives of the research and limitations of the study.

1.6.2 Review of Literature

Chapter two contains review of literature. A review of the literature is done in this chapter. Literature about evolution of the hygiene and sanitation in hotel.

1.6.3 Research Methodology

Chapter three includes research methodology. A methodology followed for the research such as type of research, techniques of data collection is described in this chapter.

1.6.4 Presentation and Analysis of Data

Chapter four includes the interpretation and the analysis of the data obtained through survey, interview and other different methods. It is the systematic arrangement or presentation of the data using appropriate statistical tools.

1.6.5 Summary, Conclusion and Recommendation

Lastly, chapter five contains results, summary, conclusion, recommendation and references at the end of this research. Recommendation will be based on the findings of the research.

Chapter – 2

Review of literature

Review of Literatures is supposed to revise the eminent literature relating to the various book, article, journals, bulletins, report news, statement, and project work etc. The main purpose is to find out what works have been done in the area of the research problem under the study and what has been done in the field of research study being undertaken.

Sanitation is the hygienic means of promoting health through prevention of human contact with the hazards of wastes. Hazards can be physical, microbiological, biological or chemical agents of disease. Wastes that can cause health problems include human and animal feces, solid wastes, domestic wastewater industrial wastes and agricultural wastes. (Essential of food safety and hygeiene- David Zachary McSwane, Nancy Roberts Rue, Richard Linton).

Food safety is a matter that affects anyone who eats food. Whether or not a person consciously thinks about food safety before eating a meal, a host of other people have thought about the safety of that food, from farmers to scientists to company presidents to federal government officials and public health officials. Ensuring the safety of food is a shared responsibility among producers, industry, government, and consumers. Safe food is food that is free not only from toxins, pesticides, and chemical and physical contaminants, but also from microbiological pathogens such as bacteria, parasites, and viruses that can cause illness.(Principle of food sanitation- Norman G. Marriott, Robert0B.Gravani).

Food safety is responsibility of every person who involved in food service operation to handle food.According to Nieto-Montenegro, Brown and Labarde (2008), general food handling mistakes beside serving contaminated raw food also includes inadequate cooking, heating, or reheating of food consumption of food from unsafe sources, cooling food inappropriately and allowing too much of a time lapse. Those errors might lead to food poisoning. Many studies identify the need for training and education of food handlers in public hygiene measures on microbiological food hazards, temperature ranges of refrigerators, cross contamination and personal hygiene (Ogden, 2003; Bas et. al., 2004;Worsfold and Griffith, 2010). However, in some preceding studies show no differences between staff who attended educational course with those who did not (Almanza, Namkung, Ismail and Nelson, 2007; Afifi and Abshelaibi, 2012). This statement is supporting by several studies (Compos, Cardoha, Pinheiro,Ferreira, Azevedo and Stamford, 2009; Thobaben, 2010) and it shows that although training may increase

Such as person thinks that preparing and handling food hygiene is important and necessary, they are likely intend to engage the behaviour. Vladimirov (2011) point outs the correlation of positive behaviour, attitudes and continued education of food handlers towards the maintenance of safe food handling practices. Contradict with Bas et. al. (2004) in their study establish that attitude scores of the food handlers toward foodborne diseases prevention and control was poor as well as hygiene practices scores were even low.

Social cognitive models from the area of health psychology frequently posited as important implement in improving both forecast and intervention research in safe food handling (Rennie, 1995). One such model is Health Belief Model (HBM) by Rosenstock in year 1975; which considers barriers and benefits of engaging in safe food handlings as well, as how severe food poisoning is seen to be and the degree of susceptibility to the illness. HBM consists of five variables but the researcher is focusing on two variables related to study that perceived susceptibility and barrier of taking actions. Perceived susceptibility is belief on perceived chances that one can influence by specific condition or disease (Azjen, 1980; Hilton,2002). For example, it would be presume that more susceptible one feels to foodborne illnesses, the more critical one would foresee the outcomes. As for perceived barriers are indicative of the challenges one expects when attempting to engage in health behaviour. For example food handlers believe that washing hands would avoid foodborne illness, but they identify time constraints and lack of facilities is barrier to comply with this behaviour.

It is necessary food handler to have responsibility for ensuring the production of safe foods, and their knowledge, attitudes and practice preventing from any food poisoning cases (Angelillo, 2000). Human handling errors have been responsible for most outbreak of foodborne illness.

In preventing human error, channeling hygiene knowledge through education may reduce the risk of foodborne illness. Gibson et al. (2002) suggest people who involved in providing, processing and service of meal required to involved with hygienic food preparation and the education. This demonstrates that the level of education is a significant factoring ensuring and main training appropriate food practices (Jianu & Chiş, 2012).

Figure 1: Conceptual Framework

Hypotheses:

Hypothesis: The Sanitization, Personal Hygiene and Hotel Environment are significantly important for growing hotel industry and also to attract the customer for their satisfaction.

• H1: Sanitation has a significant effect on the Customer satisfaction in Hotel.
• H2: Personal Hygiene plays the significant role on the hotel industry.
• H3: Hotel Environment has a significant impact on the customer satisfaction.

Chapter 3

Research methodology

Research methodological aspect is a procedure used in making a systematic observation, obtaining data evidence or information as part of a research project or study.

To know in-depth information about the topic the researcher will discuss with the professional related for several times and other related secondary information. For the preparation of the report data will be collected from both primary as well as secondary sources which will include; text books, research articles, journals and related website links. This chapter contains a brief description of methodology that a researcher will use to fulfill the research objectives at various stages of the research.

3.1 Research Design:

Exploratory research design will be used to conduct the study. A research design is a plan of the proposed research work. A research model or design represents a compromise dictated by mainly practical considerations. Research design is a research plan providing guidelines to researcher to get answer of the research objectives and to help control experimental and error variance of a particular research problem.

3.2 Sources of Data:

Primary data will be used for the study and the data will directly be collected from hotel users. It involves collecting data from the chefs using interview whereas secondary sources involves using already published materials such as reports, websites, etc.

3.3 Population and Sample

Various hotels of Bhaktapur in Durbar square.

3.4 Data Collection Instrument:

The well-structured questionnaire will be used to collect data from the consumers of the hotels.

3.4.1 Conceptual Model

The model of this study is presented in the figure below. In this model, importance of sanitization and hygiene in hotel industry, will be studied.

3.4.2 Brand Equity Dimensions

To measure the importance of sanitation and hygiene in the field of hotel industry, three factors i.e. Sanitation, Personnel hygiene and Hotel Environment are adopted.

• a) Sanitation
• b) Personal Hygiene
• c) Hotel Environment

3.5 Structured Questionnaire:

The following will be the research question for the study:

• How sanitation, personal hygiene and hotel environment plays important role in hotel industry?

3.6 Data Analysis Procedure

The discrete frequencies will be examined to identify mean, standard deviation, minimum and maximum values. Then, correlation and regression of the four dimensions will be examined. Simple random sampling technique will be applied to collect samples. Priority, as respondents, will be given to those who are, at least, frequent visitors of the hotels.

3.7 Data Collection Procedure

The exploratory design will be experimental in terms of nature of investigation. To successfully carry out the study, the primary data will be collected through collective questionnaire. Respondents will be met at different hotels.

Chapter – 4

Summary and conclusion

4.1 Summary

Good hygiene and sanitation are of prior importance for everyone catering to the food industry. Be it home or any star rated restaurant, the food that we eat follows a large number of steps before it reaches us. From the plantation farm to the food store-houses, then to the markets, then to the vendors and then finally to us. So sanitation and hygiene are something that need to be taken into serious consideration at each and every level be it the areas where the food is prepared, manufactured or served to be kept clean always. Access to improved water and sanitation facilities does not, on its own, necessarily lead to improved health. There is now very clear evidence showing the importance of hygienic behavior, in particular hand-washing with soap at critical times: after defecating and before eating or preparing food. Hand-washing with soap can significantly reduce the incidence of diarrhea, which is the second leading cause of death amongst children under five years old. In fact, recent studies suggest that regular hand-washing with soap at critical times can reduce the number of diarrhea bouts by almost 50 per cent.

Exploratory research design will be used to conduct the study. Good hand-washing practices have also been shown to reduce the incidence of other diseases, notably pneumonia, trachoma, scabies, skin and eye infections and diarrhea -related diseases like cholera and dysentery. The promotion of hand-washing with soap is also a key strategy for controlling the spread of Avian Influenza (bird flu).The key to increasing the practice of hand-washing with soap is to promote behavioural change through motivation, information and education. There are a variety of ways to do this including high-profile national media campaigns, peer-to-peer education techniques, hygiene lessons for children in schools and the encouragement of children to demonstrate good hygiene to their families and communities. See the hygiene promotion page [link: Hygiene promotion page] for more information. Various hotels of Kathmandu City. Primary data will be used for the study and the data will directly be collected from hotel users. It involves collecting data from the chefs using interview whereas secondary sources involves using already published materials such as reports, websites, etc. To measure the importance of sanitization and hygiene in the field of hotel industry, Three factors i.e. Sanitation, Personnel hygiene and Hotel Environment are adopted.

4.2 Conclusion

On this note, we can conclude that everyone should understand the importance of personal hygienic habits and sanitation, the same time we can’t ignore the hygiene in food, water, environment and daily activities. Like personal hygiene, we should also focus on sanitation too. We should try to understand the importance of public sanitation. With these good habits, we can have a long, happy and disease-free life. So Stay Clean and Keep Smiling.

References.

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2. Angelillo, I. F., Viggiani, N. M. A., Rizzo, L., & Bianco, A. (2000). Food handlers and foodborne diseases: knowledge, attitudes, and reported behavior in Italy. Journal of FoodProtection, 63, 381–385.
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5. Elements of food spoilage and preservation BY J. A. Awan, James Chukwuemeka Okaka
6. Food Hygiene And Sanitation BY S Roday HACCP and Sanitation in Restaurants and Food Service Operations BY Lora Arduser, Douglas Robert Brown
7. Gibson, L. L., Rose, J. B., Haas, C. N., Gerba, C. P., & Rusin, P. A. (2002). Quantitative assessment of risk reduction from hand washing with antibacterial soaps. Journal of Applied Microbiology, 92(1), 136e143.icipal public schools of Natal, Brazil. Food Control, 20, 807-810.
8. Jeanroy, Amelia; Ward, Karen. Canning & Preserving for Dummies. p. 39. Jeanroy, Amelia; Ward, Karen. Canning & Preserving for Dummies. p. 41. www.reference.com/motif/health/microorganisms-which-cause-food-spoilage http://www.wisegeek.com/what is food safety management http://www.woodheadpublishing.com/en/book.aspx?bookID=835 http://labspace.open.ac.uk
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10. Nieto-Montenegro, S., Brown, J. L. & Laborde, L. F. (2008). Development and assessment of pilot food safety educational materials and training strategies for hispanic workers in the mushroom industry using the health action model. Food Control, 19(6), 616 633.
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15. Tricket, Jill (2001-07-15) (in English). The prevention of food poisoning. p. 8. ISBN 9780-7487-5893-7 http://www.fnbfleet.com/blog/importance-of-hygiene-sanitation-in-hospitality-industry)
16. Understanding Food: Principles and Preparation – Page 574 BY Amy Brown Fungi and Food Spoilage BY John I. Pitt, Ailsa Diane Hocking http://culinaryarts.about.com/od/safetysanitation/a/bacteria.htm

Abstract

The study assessed the effectiveness of demonstration, discussion and recitation teaching methods on knowledge and practice of food hygiene among almajirai in tsangaya in Kano Municipal, Nigeria. A quasi-experimental design was adopted for the study. A sample of 147 participants was drawn using a multi-stage sampling procedure. Participants were assigned to three groups and lesson on food hygiene was taught to them for seven weeks using demonstration, discussion and recitation methods respectively. Paired sample t-test and Analysis of Variance (ANOVA) were used to determine the effectiveness of the three methods on knowledge and practice of food hygiene at 0.05 alpha level of significance. The findings revealed that demonstration, discussion and recitation teaching methods have significant effect on knowledge of food hygiene and discussion teaching is the most effective; there is no significant effect on food hygiene practice. The findings also revealed that the three methods were not significantly effective in eliciting positive change on food hygiene practice of almajirai. It was concluded that seven weeks treatment protocol using demonstration, discussion and recitation teaching methods is effective in improving knowledge but not effective in eliciting positive change on food hygiene practice among Almajirai in Tsangaya in Kano Municipal, Nigeria. To elicit positive changes on food hygiene practices of almajirai in Kano Municipal and elsewhere, future intervention should increase the treatment protocol from 7 weeks to 10-12 weeks using a limited number of participants from each group (25-30).

Keywords: Almajirai, food hygiene, tsangaya, teaching methods.

Introduction

Teaching methods are meant to facilitate learning and aid in behavioural change. According to Saha, Poddar and Mankad (2005), the effectiveness of teaching method depends not only on what is being taught (content) but also on how it is taught (method). Therefore, selection of appropriate teaching methods and tools are essential for conducting effective food hygiene education programmes. Some empirical studies reported that the teaching method used in imparting knowledge in tsangaya which is basically recitation method have failed to make significant impact in improving knowledge and eliciting positive behavioural change among almajirai (Bano, 2008; Hassan, 2014).

To impart knowledge and inculcate good practices with regards to hygiene, the health educator should identify effective teaching methods and prepare communication materials that will suit the learner’s need so that positive knowledge and behaviour will be imparted to promote good hygiene practices (Rezei, Seydi & Alizadeh, 2004). Hygiene education messages can be communicated in different ways such as demonstration method, lecture method, discussion, recitation, posters, drama, storytelling, mass media, and home visits. According to Sjoberg and Errickson (2010), stated that no single method is always effective. However, teaching methods to be used in promoting hygiene practices should be those that will strengthen and empower individuals and community to work for change.

For school-age children, nutrition education has not only been shown to improve knowledge and skills but also eating and physical activity behaviours as well as health status (Yoon, Yang, Her, 2000; Rasanen, Lehtinen, Niinikoski, 2002; Belansky, Romaniello & Morin, 2006). According to Contento, Randell and Basch (2002) nutrition hygiene knowledge is integral to the achievement of healthful dietary behaviour and consequently in the improvement of diet quality.

Almajirai are children sent to traditional Qur’anic schools known as “tsangaya” by their parents to learn the recitation, writing and memorization of the holy Quran (International Institute of Islamic Thought [IIIT], 2004). Furthermore, almajiranci, is a system recognised by some individuals as service to Islam in Kano Municipal Local Government of Kano State and other states in the Northern Nigeria which may be surrounded with a lot of health hazards that may increase the risk of diseases and other infections that are related to poor nutritional hygiene practices and caused permanent damage among the almajirai’s (Hassan, 2012).

Kano-Municipal Local Government is a local government in Kano State, Nigeria. It is an urban settlement located within the ancient city of Kano Metropolis. Statistical data on tsangaya schools and almajirai in Nigeria shows that Kano State has the highest number of tsangaya schools and almajirai in the 36 states of the country (Kano State Government [KNSG], 2006). Furthermore, there is an estimate of 13,635 tsangaya schools and 3,004,981 almajirai across the 44 local governments of Kano State. The population of tsangaya schools and almajirai in Kano Municipal Local Government are 481 and 117,688 respectively. Majority of the almajirai in Kano Municipal are within the ages of 10-16 years living in different political wards and settlements (KNSG, 2009).

Tsangaya is an institution or school where the holy Qur’an is taught on a boarding basis to both children and adults (Iguda, 2007). The tsangaya institution is mainly for male students. In reality, tsangaya are often places for learning and behaviour change. The almajirai in tsangaya lives in poor conditions and unhygienic environment with little government support. They also have little or no access to good diet care as offered to students in formal schools (Abdulmalik, 2011).

The four tsangaya schools used in this study have the same characteristics. They are all located in sub-urban settlement; they beg for food they eat and no inspection is carried out to check for their food hygiene practices. Furthermore, they are basically taught from the holy Quran and Hadith in these tsangaya using the same method (recitation and memorization).

Moreover, the behaviour and practices of these almajirai are supposed to be guided by the holy Quran and the dictate of the Hadith. Islamic education through Quran and Hadith encourages hygiene practices. The Quran and Hadith in many of their verses specifically stated that cleanliness and hygiene are parts of the basic requirements to worship God (Quran, 2:2; 6:31, Al-nawawi, 119:798). It is therefore, expected that these almajirai should be seen observing food hygiene and cleanliness all the time. Unfortunately, this seems not to be the case based on personal observation of the researcher. The contradiction between the teaching of the holy Quran and Hadith and the practice of almajirai with respect to keeping food hygiene constitute a problem to the society. It was against this background that this study was designed to assess the effectiveness of demonstration, discussion and recitation teaching methods on knowledge and practice of hygiene among almajirai in tsangaya in Kano Municipal Local Government Area, Nigeria

Hypotheses

The following null hypotheses were tested:

1. Ho1: Demonstration, discussion and recitation teaching methods do not have significant effect on knowledge of food hygiene among almajirai in tsangaya in Kano Municipal, Nigeria.
2. Ho2: Demonstration, discussion and recitation teaching methods do not have significant effect on food hygiene practice among almajirai in tsangaya in Kano Municipal, Nigeria.
3. Ho3: Demonstration, discussion and recitation teaching methods do not significantly differ in their effectiveness in improving knowledge of food hygiene among almajirai in tsangaya in Kano Municipal, Nigeria.
4. Ho4: Demonstration, discussion and recitation teaching methods do not significantly differ in their effectiveness improving food hygiene practice among almajirai in tsangaya in Kano Municipal, Nigeria.

Methodology

Research Design

Pre-test-post-test experimental design was adopted for this study. The purpose of using this design was to compare the three experimental groups with a control group in order to determine the effectiveness of each method on knowledge and practice of food hygiene among almajirai in tsangaya in Kano Municipal local government, Nigeria.

Population and Sample

The population of tsangaya in Kano Municipal Local Government is 481 while that of almajirai were 117,688 respectively (KNSG, 2009). A total of 147 almajirai were drawn as samples for this study using a multi-stage sampling procedure. Simple random sampling method was used to select three political wards from the existing fifteen (15) political wards in the study area, purposive sampling was used to select four tsangaya that have a population of 300 – 350 almajirai from each ward. Fifty (50) almajirai were drawn from each tsangaya as sample using simple random sampling balloting. Moreover, each tsangaya comprising of fifty almajirai was randomly assigned to demonstration, discussion and recitation groups respectively.

The instrument for data collection

A test to assess knowledge of food hygiene and a self-developed questionnaire named Almajirai Food Hygiene Practice Assessment Questionnaire (AF-HPAQ) were used as instrument for data collection. The questionnaire was validated by experts in Community Health and Sociology and a reliability index of 0.86 was obtained using split-half method.

Procedure for data collection

A test was given to almajirai in the three groups; demonstration, discussion and recitation to assess their baseline knowledge on food hygiene. At the same time, a self-developed questionnaire was administered to them to seek their baseline information on food hygiene practices. For the almajirai that could read and write, items in the instruments were read to them and their responses were tick [√] by the researcher. Lessons were conducted to almajirai by the researcher with the help of 3 research assistants, one from each group using demonstration, discussion and recitation teaching methods over a period of 7 weeks. Koundinya and Martin (2011) supported the idea that health education teaching methods can be effective for 6 weeks and above. Meanwhile, lessons on different topics of food hygiene were conducted once in a week for 30 minutes lessons.

After seven weeks treatment protocol using different teaching methods to teach the almajirai, the same test and the questionnaire administered at pre-test were also administered to them to assess the effectiveness of the treatment protocol on knowledge and practice of food hygiene at post-test.

Method of data analysis

Mean and standard deviation were used to answer the research questions. Paired-sample t-test and Analysis of Variance (ANOVA) were used to test all the hypotheses at 0.05 level of significance.

Results

Ho1: Demonstration, discussion and recitation teaching methods do not have significant effect on knowledge of food hygiene among almajirai in tsangaya in Kano Municipal, Nigeria.

Table 1: Summary of independent t-test on effect of demonstration, discussion and recitation teaching methods on knowledge of food hygiene among almajirai in tsangaya in Kano Municipal, Nigeria: Teaching Method

Test

X

N

S.D±S.E

t

df

P

Demonstration

Pre-test

41.26

50

12.764±1.805

-1.736

49

.084

Post-test

46.48

50

18.876±2.669

Discussion

Pre-test

40.62

50

17.632±2.494

-3.465

49

.001

Post-test

55.26

50

21.902±3.097

Recitation

Pre-test

41.28

47

21.731±3.170

-.994

46

.326

Post-test

45.96

47

19.072±2.728

Demo: t=-1.736, t=49, P>.05; Discuss: t=-3.465, df=49, P.05

The mean score of post test (46.48) is > the pre-test score (41.26) on knowledge of food hygiene among almajirai taught using demonstration method. The results further indicated insignificant gain in knowledge. Hence, the Ho is accepted, meaning that demonstration teaching method has no significant effect on knowledge of food hygiene among almajirai in tsangaya in Kano Municipal. Meanwhile, Table 1 revealed that the mean score of post test (55.26) is > the pre-test score (40.62) among almajirai taught using discussion teaching method, the results also shows significant gain in knowledge. Hence, the Ho is rejected, meaning that discussion teaching method have significant effect on knowledge of food hygiene. The table also shows that the mean score of post test (45.96) is > the pre-test score (41.28) among almajirai taught using recitation teaching method, the results also shows insignificant gain in knowledge. Hence, the Ho is accepted, meaning that recitation teaching method have no significant effect on knowledge of food hygiene.

Ho2: Demonstration, discussion and recitation teaching methods do not have significant effect on food hygiene practice among almajirai in tsangaya in Kano Municipal, Nigeria.

Table 2: Summary of independent t-test on effect of demonstration, discussion and recitation teaching methods on food hygiene practice among almajirai in tsangaya in Kano Municipal, Nigeria: Teaching Method

Test

X

N

S.D±S.E

t

df

P

Demonstration

Pre-test

15.60

50

3.796±.537

-7.184

49

.000

Post-test

20.14

50

2.726±.385

Discussion

Pre-test

16.90

50

3.417±.491

-6.419

49

.000

Post-test

21.02

50

2.208±.312

Recitation

Pre-test

17.77

47

3.177±.463

-3.858

46

.000

Post-test

20.28

47

2.740±.400

Demo: t=-7.184, t=49, P the pre-test score (17.77) among almajirai taught using recitation teaching method, the results also shows significant change in practice. Hence, the Ho is rejected, meaning that recitation teaching method have significant effect on food hygiene practice.

Ho3: Demonstration, discussion and recitation teaching methods do not significantly differ in their effectiveness in improving knowledge of food hygiene among almajirai in tsangaya in Kano Municipal, Nigeria.

Ho4: Demonstration, discussion and recitation teaching methods do not significantly differ in their effectiveness improving food hygiene practice among almajirai in tsangaya in Kano Municipal, Nigeria.

Table 3: Summary results of ANOVA on the most effective teaching method among demonstration, discussion and recitation on knowledge and practice of food hygiene:

Sum of Squares

df

Mean Square

F

Sig.

Knowledge of Food Hygiene

Between Groups

2698.815

2

1349.408

3.368

.037

Within Groups

57696.015

144

400.667

Total

60394.830

146

Food Hygiene Practice

Between Groups

22.303

2

11.152

1.693

.188

Within Groups

948.404

144

6.586

Total

970.707

146

F=3.368, df: 2,144, P 0.05

The results on Table 3 showed significant difference in effectiveness of knowledge of food hygiene among almajirai taught using demonstration, discussion and recitation teaching methods (F=3.368, df: 2,144, P 0.05). This finding has provided basis for retaining null hypothesis 4. This signifies that demonstration, discussion and recitation teaching methods were not significantly effective in eliciting positive change on food hygiene practice among almajirai in tsangaya in Kano Municipal, Nigeria.

Table 4: LSD posthoc analysis summary of anova on the effectiveness of demonstration, discussion and recitation teaching method on knowledge of food hygiene among almajirai in tsangaya in Kano Municipal.

(I) Group

(J) Group

Mean Difference (I-J)

Std. Error

Sig.

95% Confidence Interval

Lower Bound

Upper Bound

Demonstration Method

– Discussion Method

-8.780*

4.003

.030

-16.69

-.87

-Recitation/Memorization Method

.523

4.067

.898

-7.52

8.56

Discussion Method

– Demonstration Method

8.780*

4.003

.030

.87

16.69

– Recitation/Memorization Method

9.303*

4.067

.024

1.26

17.34

Recitation/Memorization Method

– Demonstration Method

-.523

4.067

.898

-8.56

7.52

– Discussion Method

-9.303*

4.067

.024

-17.34

-1.26

*. The mean difference is significant at the 0.05 level.

Results of LSD Post – hoc comparison on Table 4 indicates that there was a significant difference in the effectiveness of demonstration and discussion teaching methods (P< .05); and discussion is more effective than a demonstration in improving knowledge of food hygiene among almajirai in tsangaya in Kano Municipal, Nigeria. The table also indicates significant difference between discussion and recitation teaching methods (P< .05); and discussion is more effective than recitation teaching in improving knowledge of food hygiene among almajirai in tsangaya in Kano Municipal, Nigeria.

Discussion

This study compared the effectiveness of demonstration, discussion and recitation teaching methods on knowledge and practice of food hygiene among almajirai in tsangaya in Kano Municipal, Local Government Area, Nigeria.

The outcomes of this study shows significant difference among demonstration, discussion and recitation teaching methods on knowledge of food hygiene among almajirai in tsangaya in Kano Municipal Local Government Area, and discussion teaching method was the most effective method in improving knowledge of food hygiene. The finding of this study is consistent with report of Jarvis (2004) which stated that discussion teaching method is the most effective in imparting knowledge on hygiene among school children. This method is designed to motivate the learners to discover understanding and feelings concerning the subject matter being taught. Discussion teaching method has been identified as an inclusionary and participatory teaching method that facilitates critical thinking skills in learners (Brookfield, 2004), which is an essential component for improving knowledge regarding hygiene. Meanwhile, findings of (McGlynn, 2005; Peck, Ali, Matchock, & Levine, 2006) are consistent with the findings of this study. These findings revealed that discussion teaching technique was more effective over lecture, demonstration and recitation because it encourages students to actively engage in classroom activities, and it has been found to promote deeper levels of thinking and better facilitate encoding, storage, and retrieval.

It was revealed by the outcome of this study that demonstration, discussion and recitation were significantly effective in eliciting positive change on food hygiene practice of almajirai in tsangaya in Kano Municipal local government area of Kano State. This study was consistent with findings of (Bryan, 1998; Evans, Madden, Douglas, Adak, O’Brien, Djuectic, Wall & Stainwell, 1998). These findings revealed that health education intervention using different teaching methods such as demonstration, discussion and recitation methods have no impact on nutritional educational programs and significantly brought changes in food hygienic behaviours and adoption of recommended food hygiene practices (Gentry-Van, Laanen & Nies, 1995; Wardlaw, 1999; Dean, Reames, Tuuri, Keenan, Bankston, Friendship & Tucker, 2008).

Summary

This study compared the effectiveness of demonstration, discussion and recitation teaching methods on knowledge and practice of hygiene among almajirai in tsangaya in Kano Municipal, Nigeria. The results of the findings of this study revealed that discussion teaching method have significant effect on knowledge of food hygiene while demonstration and recitation teaching methods have no significant effect on knowledge of food hygiene among almajirai in tsangaya in Kano Municipal, Nigeria. The findings also revealed that demonstration, discussion and recitation teaching methods have significant effect on food hygiene practice. Furthermore, the findings show significant difference in the effectiveness of demonstration, discussion and recitation teaching methods and discussion teaching method was the most effective method over demonstration and recitation teaching method. The finding of the study also shows no significant difference in the effectiveness of food hygiene practice among almajirai taught using demonstration, discussion and recitation teaching methods that demonstration, discussion and recitation teaching methods.

Conclusion

Based on the findings of this study, it was concluded that:

1. Demonstration and recitation teaching methods do not have impact in improving knowledge of food hygiene of almajirai in tsangaya in Kano Municipal, Nigeria.
2. Discussion teaching method has impact on improving knowledge of food hygiene of almajirai in tsangaya in Kano Municipal, Nigeria.
3. Discussion teaching method is the most effective teaching method over discussion and recitation teaching methods in imparting knowledge of food hygiene among almajirai in tsangaya in Kano Municipal, Nigeria.
4. Demonstration, discussion and recitation teaching methods have impact on food hygiene practice of almajirai in tsangaya in Kano Municipal, Nigeria, though the impact could illicit positive change in practice and behaviour of almjirai.
5. The impact of demonstration, discussion and recitation teaching methods do not differ in eliciting positive change on food hygiene practice of almajirai in tsangaya in Knao Municipla, Nigeria.

Recommendations

Based on the findings and conclusion of this study, the following recommendations were made:-

1. Kano Municipal Local Education Authority in collaboration with Federal Government through Universal Basic Education Commission, and Kano State Universal Basic Education Board in its attempt to formalize tsangaya education, should include food hygiene education, as part of its tsangaya curriculum in order to improve the knowledge of almajirai and change their practices on issues related to hygiene in order to prevent diseases associated with poor hygiene.
2. Health care providers particularly health education teachers should give opportunity of exchange of ideas and should encouraged positive involvement of almajirai in the teaching process using discussion teaching method in order to improve their knowledge and make the concept of food hygiene more meaningful to them.
3. Practical ways and strategies of observing food hygiene should be demonstrated and emphasized to almajirai in tsangaya to make the lesson workable in order to illicit positive change in their hygienic behavior. Instructional aids (teaching aids) such as

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