Hand Washing Among Nurses and Midwives in Rwanda: Is It Compliance or Adherence?
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Session presented on Saturday, July 23, 2016: Purpose: It is paramount that hand washing (HW) adherence among health care workers (HCWs) be increased and sustained as it has been found as one of the simplest yet most effective intervention in healthcare to prevent nosocomial infections(Karaaslan et al., 2014 ). According to (White et al., 2015), in order to improve their adherence, it is essential to understand the cognitive determinants of HW decisions for nurses. The cognitive determinants play a key role in promoting many elements of HW. Nonetheless, the concepts of adherence and compliance to HW guidelines are often used interchangeably as if they mean the same thing or have the same outcome. Adhering to HW practice is more than complying with HW guidelines. It is about making HW a habitual practice. This presentation re-examines a study in which the primary aim was to determine the compliance with HW among nurses and midwives caring for newborn babies at selected health facilities and the extent to which demographic and cognitive factors predict nurses' HW compliance. It further raised the question if the findings were just compliance or adherence. Methods: a cross-sectional approach encompassing descriptive and quantitative methods was used to collect data from nurses and midwives (N=134) who were providing care to newborn babies. An anonymous self-administered questionnaire (Alpha coefficient for the multi-item scales ranging from .88 to .91) was used to collect data within 3 weeks. Factors such as age, education level, years after completion of basic professional studies, years of employment in the current health facility, attitudes, perceived behavioural control, intentions and HW compliance by colleagues' nurses/midwives were used as independent variables. Bivariate analysis using Pearson correlation (significant at the 0.01 level 2-tailed) was carried out to determine any relationship between independent variables and HW compliance rates, and multiple regression analysis was done to determine the most unique independent predictors to HW compliance. Results: Of the 139 self-administered questionnaires distributed, 134 were completed and returned to the researcher giving a rate of 96.4%.respondents in the study. The majority (74.6%) of respondents reported their highest level of education as secondary certificate (A2), compared to 18.7% of the sample who had Advanced diploma (A1) and to 6.7% with degree (A0). The results showed that 64.5% of participants (n=86) did not get any formal training on HW after completion of their basic education, compared to 40.3% who experienced a HW promotional campaign in the past. Nevertheless, the results demonstrate that a mean self-reported HW compliance rate was 82.00% (SD= 13.60). A compliance rate of 80% or greater was confirmed by most of the participants in the study (79.1%). The highest reported rate of HW was HW after exposure to the newborn's body fluids (M= 89.33%; SD= 14.878), while results revealed that nurses tend to perform less HW after touching an object in the vicinity of the patient (73.43%; SD=22.81). The findings of this study from a Pearson correlation analysis indicated that self-reported HW compliance was positively correlated with attitudes (r = 0.388, p < 0.01), Perceived behavioural control (r = 0.261, p < 0.01), Intentions (r = 0.576, p < 0.01), and HW compliance by colleagues nurses and midwives (r = 0.493, p < 0.01). The variables related to demographic factors were not statistically associated with respondents' self-reported HW compliance. Furthermore, the model used for multiple regression revealed that the only three variables which were making a statistically significant contribution to the prediction of self-reported HW compliance were attitudes, intentions, and HW compliance by colleagues. The results indicated that intentions was found to have the strongest prediction to self-reported HW compliance (B = .390; SE= .090, p< .0005), HW compliance by colleagues showed a relatively strong prediction to self-reported HW compliance (B= 2.175; SE= .527, p < .0005) than attitudes (B = 1.957; SE= .970, p = .046). Although the study found that the overall mean self-reported HW compliance among Rwanda nurses and midwives was high, and it was brought to our attention that intention to wash hands and the pressure from colleagues were the most predictors to HW. However, the authors believe that results from the study would have been different if another method of collecting data was used (for example observational approach). This belief is based on the fact that the high self-reported hand-washing compliance rates from studies that used self-administered questionnaires were not consistent with the results from observational studies, which show very low hand-washing compliance rates. For example, a study conducted by (Al-Wazzan et al., 2011) revealed a HW observed compliance rate of 33.4% among nursing staff in secondary care hospitals in Kuwait, which was contrasting with 90% compliance rate self-reported by nurses, stating they always washed their hands upon practicing patient care activities. This highlights the limitation of using a self-reported approach in such kind of studies whereby respondents tend to report inflated HW rates than they actually do; desirable behaviour is self-reported more frequently than it is observed. In looking at the outcome, further questions were raised as to what would have been the outcome if the emphasis of the study had been on adherence rather than a self-report of compliance. Conclusion: With the limitations of this study in mind, the researcher concluded that though this study may have revealed a high self-reported HW compliance, the future of these type of studies would be to examine adherence, rather than compliance with HW. The study may have also suggested a high level of awareness; attitudes and intentions which were shown to be predictors of HW compliance among nurses and midwives, these may not translate to a habitual, consistent practice beyond mere compliance. Referring to other studies that used observational approach, although the design of the current study was not intended to compare self-reported and observed HW, the authors suggest that observational audit of HW practices be explored to provide an informed situation of HW adherence, and improve infection control in health facilities of the eastern province in Rwanda.