Introduction
The purpose of the Scotland Infection Prevention and Control Education Program (SIPCEP) is to establish a pre-determined pathway of infection prevention and control through both education and practice. It is intended to enable healthcare staff and students who strive to become professionals in the healthcare field to improve their knowledge and skills surrounding infection prevention and control as part of their roles. Both hand hygiene and personal protective equipment (PPE) represent safe measures intended to protect an individual from contagious illnesses, including COVID-19, and allow remove contaminants in everyday life. Hand hygiene is defined as the way of cleaning one’s hands that significantly reduces potential pathogens on the hands and is considered a primary measure for preventing infection transmission (CDC, 2018). PPE is equipment worn for reducing exposure to dangers, including chemical, physical, biological, and others; such equipment includes items such as gloves, respirators, coveralls, and full body suits (NIOSH, 2018). In the context of the COVID-19 pandemic, both hand hygiene and PPE have been shown to play crucial roles in safeguarding the population against illness, with healthcare professionals expected to follow the established standards while also educating the public about improved adherence to safety measures.
SIPCEP Principles Discussion
Hand hygiene represents one of the pillars of disease prevention. Handwashing practices within the patient care setting emerged in the early nineteenth century, evolving and developing over the years with evidential proof of its significance (Toney-Butler et al., 2022). Combined with other practices of hand hygiene, handwashing resulted in the decreased presence of pathogens causing nosocomial or hospital-acquired infections (HAI) because healthcare providers’ contaminated hands are the leading cause of their spreading (Engdaw et al., 2019). Thus, proper hand hygiene practices decrease microorganisms’ proliferation, lowering the risks of infections and, therefore, general healthcare costs and hospital length of stays.
The removal of bacteria is usually done in five steps recommended by the World Health Organization’s “Five Moments for Hand Hygiene.” A healthcare provider should wash one’s hands before touching or coming into contact with a patient, before conducting a clean or aseptic procedure, after an exposure risk to bodily fluids and gloves’ removal, after contact with a patient, and after touching surfaces or inanimate objects in the immediate surroundings of the patient (WHO, 2009).
The importance of knowledge of hand hygiene practices stems from the impact of the pathogenic spread of microorganisms, which calls for discussing skin anatomy. From the microbiological perspective, it is notable that healthy skin is being colonized with resident flora, which are microorganisms residing below its surface and stratum corneum (Toney-Butler et al., 2022). Microbial antagonism is one of the flora’s functions, even though bacteria are not pathogenic on intact skin. However, in areas such as non-intact skin, the eyes, and sterile body cavities, an infection can occur. Thus, it is crucial for healthcare workers to avoid the spreading of transient microorganisms through direct contact with patients, surfaces, or different contaminated objects. While the transient flora colonizes the superficial layers of the skin, it can be removed through routine handwashing more easily compared to resident flora.
Personal Protective Equipment
As a further but not supplemental measure to hand hygiene, PPE has been widely used in healthcare settings, acting as a barrier between potentially infectious materials and skin, eyes, mouth, and nose to block the transmission of contaminants (FDA, 2020). Besides, PPE may be used for protecting patients at a higher risk of contracting infections through surgical procedures or who have medical conditions such as immunodeficiency. Notably, the effective use of PPE is concerned with the proper removal and disposal of contaminated equipment to prevent exposing the wearer to infection and others surrounding them. Thus, PPE will collect potential contaminants on its surfaces, its correct use entails not only the knowledge of how to put it on but also how to take it off.
The regulation of appropriate measures for wearing PPE within the healthcare context is carried out by the US Food and Drug Administration, which requires the meeting of voluntary consensus standards for protection. The equipment under regulation includes surgical masks, N95 respirators, gowns, and medical gloves (Reddy et al., 2019). Importantly, substantial equivalence to the Premarket Notification or 510(k) clearance is expected to be demonstrated by manufacturers in terms of barrier performance and resistance to snags and tears (FDA, 2020). Thus, healthcare personnel should use FDA-approved PPE for the highest levels of possible protection. The appropriate adherence to PPE regulations will reduce infection risks, enhance patient management, and safeguard everyone involved in clinical procedures.
With the emergence of public health risks such as the COVID-19 pandemic, the importance of preventive measures has come to the forefront. Since contemporary nursing practice is challenged by having to handle multiple patient cases daily, the knowledge of appropriate hand hygiene and PPE wearing practices can enhance their and patients’ safety. Therefore, relevant and regular training of nursing personnel on adherence to hand hygiene and PPE practices is necessary to strengthen their knowledge in guaranteeing safe and effective patient care.
Critical Review
Research on hand hygiene compliance and the use of PPE in the healthcare setting is diverse and encompasses a range of contexts. Notably, prior to the COVID-19 pandemic, there was a paradigm shift occurring in the area of hand hygiene, such as the change from handwashing with soap and water to using alcohol-based rubs (Vermeil et al., 2019). Before 2020, nurses adhered to the WHO hand hygiene standards by 63%, while allied staff adhered to them by 86.5% (Chavali et al., 2014). Besides, the following by healthcare workers of PPE standards has remained suboptimal (Williams et al., 2019). Because of this, infection prevention and control (IPAC) programs have attempted to solve the issue through extraneous interventions such as education and enhanced auditing, even though no significant change ensued (Krein et al., 2018). However, with COVID-19 posing a severe risk to health and safety and being an infectious disease, a reconsideration of PPE and hand hygiene practices had to occur.
There is a general consensus among researchers who explored the implementation of hand hygiene procedures and the following of PPE rules that the levels of adherence had to be improved. For instance, in their observational study, Krein et al. (2018) found that nurses actively failed to use PPE and transmission-based precautions, which could potentially lead to self-contamination. The failures included practice violations, procedural mistakes, or accidental occurrences, suggesting that behavioral, organizational, and environmental factors were all at play (Krein et al., 2018). The majority of violations in the healthcare setting in the use of PPE occurred when nurses came quickly into patient rooms to say something even though there could be risks of contamination (Verbeek et al., 2020). Short-term contacts with patients were not considered important enough to wear PPE, with nurses only using sanitizing gel on their hands after leaving the ward (Krein et al., 2018). This example illustrates that nurses and other healthcare personnel preferred hand hygiene to using PPE in their frequent but short interactions with patients because putting on and taking off the equipment took more time. In most instances, the workload of healthcare personnel is high, which is why they tend to forget or avoid using PPE on a regular basis.
Moreover, the lack of adherence to the proper PPE practices could be linked to the findings that medical students received PPE training sporadically or never received training that required the demonstration of proficiency (John et al., 2017). As a result, even when being trained for the medical profession, students do not have enough information on how to effectively put on and take off protective equipment to prevent self-contamination or impacting others. These findings call for embedding adequate and regular training on PPE use to address the lack of professionals’ preparation to correctly use the equipment and make it a habit.
In contrast to PPE, nurses and other healthcare personnel have shown higher levels of adherence to hand hygiene practices. As illustrated in the PPE-focused study by Krein et al. (2018), in cases when nurses had to use PPE, including short visits to patient wards, they opted for hand hygiene because it was quicker and required fewer resources to be carried out effectively. Nevertheless, challenges in hand hygiene practices remain, with levels of compliance being lower than expected (Chavali et al., 2014). Observational research showed that nurses have the highest number of contacts with patients in their everyday practices, followed by allied healthcare workers. However, the rates of adherence to hand hygiene practices were higher in the allied staff than among nurses (Chavali et al., 2014). These findings suggest that when practitioners are overloaded with their workload, they are more likely to skip hand hygiene, often unintentionally.
Healthcare personnel working in the hospital setting fail to implement hand hygiene adherence due to several reasons. The barriers to the implementation of frequent and correct hand hygiene practices included individual limitations, such as the lack of knowledge and improper attitudes and management issues, such as wrong behavioral patterns and unsuitable training and planning (Ahmadipour et al., 2022). Besides, there are barriers linked to organizations, which include heavy workloads, improperly designed wards, insufficient and lacking equipment, or lower quality of equipment (Ahmadipour et al., 2022). Both outside and within the context of the COVID-19 pandemic, the lack of practitioners’ awareness of hand hygiene practices led to poor adherence.
If healthcare workers do not have enough training on hand hygiene, they are more likely to have negative attitudes toward it and fail to show the required levels of adherence (Atif et al., 2019). In addition, the lack of obvious contamination on the hands and the substitution of gloves for hand hygiene present additional barriers to hand washing practice (Atif et al., 2019). Nevertheless, compliance tends to decrease over time, even after the pandemic, because of practitioners’ poor understanding of the procedures and the absence of effective educational interventions for recognizing hand hygiene opportunities.
Discussion of COVID-19
The relevance of the two SIPCEP topics to the contemporary nursing practice within the COVID-19 pandemic context is highly important. The studies explored in the critical review tend to be concerned with the pre-pandemic healthcare context; however, with the disease posing a significant challenge to public health, the relevance of PPE and hand hygiene increased. As found by Makhni et al. (2021) in their study, before the pandemic, the monthly compliance with hand hygiene practices across all hospital units was 54.5%, while during it, it reached a daily peak of 92.8%. As the severity and impact of the pandemic decreased, compliance with hand hygiene practices reduced (Seid et al., 2022). Nevertheless, the importance of hand hygiene should not decrease in significance because COVID-19 has shown some variability and increases in its resistance, showing that preventive measures must be implemented regularly.
PPE has been used as an additional but crucial protective measure for mitigating the spread of infectious diseases within the COVID-19 context. When the pandemic was at its peak, WHO (2020) reported that there was a severe lapse in the global supply of PPE, which meant that not all healthcare facilities had access to the necessary amount of equipment to ensure the maximum protection of their personnel. This increased the risks of both patients and healthcare staff getting infected by a coronavirus in the absence of enough equipment that has to be changed and replaced regularly (WHO, 2020). Notably, in their article, Livingston et al. (2020) suggested that the sourcing of PPE during the COVID-19 pandemic could increase with the reusing of equipment that could be cleaned, repurposing of objects such as gowns and eye and face shields, and reducing non-essential services.
While before the pandemic, the rates of adherence to PPE practices were lower than necessary, the public health crisis posed a severe challenge to healthcare facilities. Notably, in the absence of enough equipment, it was problematic for the staff to reduce the adverse impact on patients and their relatives, which is why the number of contacts between them and nurses had to reduce (Livingston et al., 2020). For example, out-of-room room monitoring, e-consults, barriers visit, batching medications for self-administration, and other practices were introduced to lower contacts.
Conclusion
The review of the literature on nurses’ adherence to the PPE and hand hygiene standards shows that most of the failures come as a result of poor training and high workloads. When healthcare personnel deals with a lot of patients every work day, the adherence to such standards decreases because they do not have enough time, may forget, or may dismiss their importance altogether. These challenges point to the need for adequate appraisal of the practices and effective education targeted at the personnel who deals with patients on a regular basis.
Today, as the availability and access to PPE have normalized, it is essential to implement training interventions to educate staff and develop scenarios that could be carried out in cases of a future public health crisis. The same principle must apply to hand hygiene practices to maintain them on a high level so that it plays a role as a preventive measure in light of possible upcoming health issues. Through training of personnel and education of the general public, it is expected to increase the adherence to hand hygiene and PPE use in the complex post-COVID-19 environment.
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