¹Critical Care Nursing Department, Kulliyyah of Nursing, International Islamic University, Malaysia
²Former Scholar, University of Queensland, Australia
3QIMR Berghofer Medical Research Institute, Brisbane Queensland, Australia
4School of Nursing, Midwifery and Social Work, The University of Queensland, Australia
4Queensland Children's Hospital Brisbane, Australia
5University of the Sunshine Coast, Sippy Downs,Australia
*Corresponding Author’s Email: noorazizah@iium.edu.my
As of the 31st July 2020, more than 17 million confirmed COVID-19 cases with over 668k deaths have been reported worldwide (World Health Organisation (WHO), 2020). The COVID-19 virus is genetically similar to the Severe Acute Respiratory Syndrome (SARS) and the Middle East Respiratory Syndrome (MERS) (Nussbaumer‐Streit et al., 2020; Zhao et al., 2020). However, initial investigations of the basic reproduction number (Ro) of COVID-19 shows higher transmissibility than SARS and MERS (Zhao et al.,2020). The mode of transmission of COVID-19 is mainly through close contacts via droplets from human to human (World Health Organisation (WHO), 2020). Whilst researchers around the world are focused on developing a vaccine for COVID-19, transmission preventative measures become the most effective means of response.
The World Health Organisation (WHO, 2020) released disease outbreak news in late January emphasising that coronavirus is largely preventable with frequent hand washing in addition to medical masking, and appropriate use of personal protective equipment. The emphasis on performing hand hygiene is not new to healthcare workers (HCWs) who are expected to practice good hand hygiene to prevent healthcare associated infections (HAIs) (World Health Organization (WHO), 2009).
A decade ago the WHO recommended Five Moments for Hand Hygiene for HCWs to prevent cross transmission within the health care settings. These moments are:
before touching a patient
before a procedure
after a procedure or body substance exposure risk
after touching a patient
after touching a patient's surroundings (World Health Organization (WHO), 2009).
In addition to the Five Moments of Hand Hygiene, the Australian Health Protection Principal Committee has recommended the following interim guidelines for HCWs when caring or collecting specimens from suspected or confirmed cases of COVID-19 (Department of Health, 2020):
“Perform hand hygiene before putting on a gown, gloves, eye protection (goggles or face shield) and surgical mask/ P2/N95 respirator)
After the consultation, remove gown and gloves, perform hand hygiene, remove eye protection, perform hand hygiene, remove P2/N95 respirator, and perform hand hygiene
Do not touch the front of any item of PPE during removal, perform hand hygiene at any point contamination may have occurred”.
Moreover, in Malaysia, the specific guidelines have been recommended by the Ministry of Health Malaysia. The ministry has republished a Guidelines COVID-19 Management No 4/2020 update on 26th February 2020 which also highlighting about hand hygiene to be practiced by all HCWs as standard precaution (Ministry of Health Malaysia, 2020). The Centre for Disease Control (CDC) has also reemphasised the important role of hand hygiene as a means to mechanically remove pathogens. Alternately 60% ethanol and 70% isopropanol present in hand sanitizers inactivate viruses that have similar properties of COVID-19 (Centre for Disease Control and Prevention (CDC), 2020).
Maintaining HCWs compliance with hand hygiene has been challenging during COVID-19 as a result of; unintentional violation due to lack of time during hectic work shifts, the nature of the working environment and emergency situations in which HCWs may forget or be distracted from performing hand hygiene and limited hand hygiene resources. In line with the WHO Multimodal Hand Hygiene Improvement Strategy, reminders of hand hygiene in the workplace are one of the key components in the conceptual framework designed to stimulate behavioural changes (World Health Organization (WHO), 2009). ‘Speaking up for hand hygiene’ is one form of reminders or real-time feedback that has a capacity to prevent, correct, intercept harm before occurring (World Health Organization (WHO), 2009 and Okuyama et al., 2014).
Despite the benefits, HCWs have been found to be reluctant to speak up for hand hygiene. For example, in a study involving 1217 healthcare workers, only 56% of them reported that they would speak up if their co-workers had poor hand hygiene practice (Pan et al., 2013). The hierarchy of the unit and feeling of shame if reminded by patients and their families also among the reasons for HCWs reluctant to speak up for hand hygiene (Schwappach, 2018). HCWs are however more likely than usual to speak up if their perceived risk of harm is high to patients and/or themselves (Bellissimo-Rodrigues et al., 2014). As COVID-19 is acknowledged as highly transmissible and dangerous, ‘speaking up for hand hygiene’ behaviours may increase during the pandemic.
Patients and their families who have had experience with HAIs have been shown to be more likely to remind HCWs to perform hand hygiene (78.4%) (Wu et al., 2013). If the family felt comfortable, they were also increasingly willing to ask nurses and doctors to clean their hands (Mohd Ali, 2020). It suggests that the perception of possible danger to their loved one provided motivation for families to speak up for hand hygiene (Freling et al., 2020). Patients’ who have COVID-19 however may not be in a position to speak up and if quarantined will not have family members present to advocate for hand hygiene.
A culture of open communication within the health care settings should be adopted where ‘speaking up for hand hygiene’ is everybody’s business. Senior staff (e.g., consultants, registrar, nurse unit managers) should talk positively about speaking up and encourage their co-workers and junior staff who violate hand hygiene rules. Moreover, the tone of reminders or feedback should be friendly and supportive enough (not finding fault/criticism) as HCWs who care are already in extreme stress.
Patients and family may use educational videos, printed or online information around playing an active part in ‘speaking up for hand hygiene’. HCWs may use verbal approaches to remind patients and families, such as:
“Please tell me if I missed to wash hands”
“Let’s us ensure we have cleaned our hands and check others as well” “We would be grateful if you could tell us if we missed washing our hands”
“I encourage you to check if I washed my hands and check if doctors, nurses, other HCWs or visitors have washed their hands when necessary”.
COVID-19 does not discriminate against gender, race, economic, education or status of a person. What really matters is to ensure that all HCWs, are performing hand hygiene, speaking up if we witness missed hand hygiene and educating and encouraging patients and families. Let us change to make ‘speaking up for hand hygiene’ our new norm.
The authors declare that they have no conflict of interest.
The authors are thankful to the institutional authority for completion of the work.
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