Personnel Characteristics and Comprehensiveness of Hospital on

Handwashing Compliance

Robert Komaria, Ermi Girsang, Ali Napiah

Faculty of Medical, Universitas Prima Indonesia, Indonesia

Keywords: Personnel Characteristics, Role of PIC, Comprehensiveness, Handwashing.

Abstract: The results of the 2018 prevention of infection control (PIC) committee regarding compliance with the

application of hand washing by doctors 53.3%, nurses 47.9% and other health workers 35.6% against a

minimum service standard of 85%. This condition is thought to be caused by individual characteristics and

hospital completeness (the role of PIC, and completeness of facilities and infrastructure). The purpose of this

study was to analyse the relationship between individual characteristics, the role of PIC and the completeness

of facilities and infrastructure to nurse compliance in the application of hand washing. This research was

conducted through a cross sectional survey approach with a population of 113 nurses with simple random

sampling technique. Data were collected through questionnaires and analysed with univariate, bivariate and

multivariate (using multiple logistic regression) methods. The results of the study of nurses less adherent to

washing their hands 64.6% and 35.4% obedient. Individual characteristics (knowledge p = 0.003 and attitude

p = 0.002), the role of PPI (p = 0.002), and completeness of facilities and infrastructure (p = 0.017) were

related to the compliance of nurses washing hands. It can be concluded that individual characteristics, the role

of PPI, and the completeness of facilities and infrastructure were an essential factors in improving compliance

with the implementation of hand hygiene.

1 INTRODUCTION

Healthcare Associated Infections (HAIs) are

infections in patients who have not been seen or are

not incubating when the patient first enters or occurs

during a patient being hospitalized for more than 48

hours, which does not appear at the time of hospital

admission or health care others (WHO, 2010).

The results of surveillance of infectious diseases

resulting from health services namely Healthcare

Associated Infections (HAI's) in US hospitals in 2013

reached 721,800 cases from 183 hospitals studied and

as many as 75,000 patients died while receiving

treatment at the hospital (CDC, 2014).

The Indonesian Infection Control Association

conducted a prevalence point survey of 11 hospitals

in Jakarta's Capital Region in 2010, showing the

HAI's incidence rate, namely surgical injury Infection

of 18.9%, infection that occurred in the urinary canal

of 15.1%, infection in primary blood flow of 26.4%,

pneumonia 24.5% and infections in other airways

15.1%, and other infections 32.1% (Perdalin, 2010).

Hospitals in the city of Medan, among others, Haji

Adam Malik Regional Hospital, have clean surgical

post-operative wound infections with a prevalence

rate of 5.6% (Nirbita, 2017). The high incidence of

HAI's indicates that transmission is still quite high

and is a threat to hospital services.

The lack of quantity and quality of hospital

infection control is closely related to compliance with

hand washing. According to the World Health

Organization (WHO) that compliance with hand

washing of health workers can control or control the

incidence of infection (WHO, 2014).

The level of compliance with hand washing in

developed countries such as the United States has not

been as expected, reaching 50%. The level of

compliance of nurses' hand hygiene did not differ

greatly at the Marmara University Hospital in

Istanbul reaching 43.2% (Karaaslan, et al, 2014).

Damanik Research (2012) and Pratama (2015) at

two hospital locations in Indonesia, Imanuel Hospital

Bandung and RSUD dr. Iskak, where the level of

compliance of nurses carrying out hand washing did

not reach half of the proportions of 48.3% and 36%.

The level of nurse compliance adheres to hand

hygiene is influenced by three factors: first, the

individual characteristic factors consist of

Komaria, R., Girsang, E. and Napiah, A.

Personnel Characteristics and Comprehensiveness of Hospital on Handwashing Compliance.

DOI: 10.5220/0010293202150220

In Proceedings of the International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical (HIMBEP 2020), pages 215-220

ISBN: 978-989-758-500-5

215

understanding, response, being busy due to heavy

workload. Second, organizational support factors

consist of standard operating procedures, rewards,

sanctions, training activities and adequate facilities /

infrastructure support, third, behavioral factors

consist of trust, confidence and other social support.

Another important thing is the role of the prevention

of infection control (PIC) committee in increasing

understanding to improve nurse compliance in the

application of hand washing for hand hygiene (Pittet,

2001; David, 2010; Turnip et al, 2020; Wijaya et al,

2019).

Karadag Research (2016); Jemal (2018); White

(2019); and Gon (2020) state knowledge, friend

suggestions, perceptions and beliefs, practices, and

consumables as determinants of hand hygiene.

Furthermore Shobowale research (2016); Kupfer

(2019): that the availability of facilities (easy access)

can improve hand washing hygiene.

Sands (2010), using the Behavior Centered

Design (BCD) theory related to behavioral change

interventions in improving hand washing compliance,

namely reporting hand hygiene, implementing hand

washing by peers, increasing interaction with patients

and other staff members, reducing stress, busyness,

and burdens cognitive related to the task.

Farhaoudi (2016) reviewed the WHO Multimodal

Hand Hygiene Improvement Strategy consisting of:

1) system changes to ensure access of health care

workers to hospital facilities with an approach to the

availability of alcohol-based hand washing facilities

in the service rooms, 2) training and continuing

education, 3) evaluation and feedback, 4) reminders

at work, and 5) providing safety climate through IPC

agencies. After intervention by carrying out and

providing a Strategy to Improve Hand Hygiene in the

service room, where the proportion of hand rubbing

behavior (18.1%) and hand washing (11.5%), there

was an increase in hand rubbing (18.1%) and hand

washing 11.5%) was much better among health

workers (p 0.001 <0.05). Zhao (2018) examines 5

aspects of the theory of Diffusion of Innovation

Theory (DIT): relative advantages, compatibility,

simplicity, testability, and observability significantly

influence hand washing practices.

A similar study by Boyce and Pittet (2011) states

that one of the obstacles in non-compliance with

washing hands is the difficulty of accessing a place to

wash hands or other tools used to wash hands. Ease

of accessing supplies of tools for washing hands,

sinks, soap or alcohol jell is very important to make

compliance according to standards. Other research

was conducted by Shobowale (2016); and Kupfer

(2019): stating the availability of hand washing

facilities or the ease of gaining access to hand

washing affects the cleanliness of hand washing.

Nurse hand washing compliance audit results at

the Royal Prima Hospital Medan in 2018 by the PIC

Committee with 53.3% doctor compliance, 47.9%

nurses and other health workers 35.6%.

Compliance is not in accordance with Minimum

Service Standards> 85%. Research is important

because hand hygiene is the duty and responsibility

of nurses and is cheap and easy to do to avoid

infection in hospitals, it only takes a strong desire and

willingness to implement. But in reality, this habit has

not gone according to expectations.

Previous studies generally used quantitative

research designs or types, mix methods, semi-

experiments with cross sectional accuracy. Theory

used by Behavior Centered Design (BCD) by Sands

(2010); Diffusion of Innovation Theory (DIT) by

Zhao (2018); Multimodal Hand Hygiene

Improvement Strategy by Farhaoudi, 2016) and other

behavioral theories. Statistical tests use correlation

and comparison (t-test) with intervention.

This research is a quantitative research. In this

study the focus is more on the determinants of hand

washing hygiene developed by Pittet. The study

results have contributed a lot to WHO and certainly

to different loci. This study uses a survey with a cross

sectional approach (data collection uses a

questionnaire and a checklist) which the observations

were simultaneously carried out. The variables were

measured after data collections. The data were

analyzed with univariate, bivariate and multivariate

(multiple logistic regression) methods to prove the

hypothesis.

2 METHOD

The study was conducted using inpatient nurses as

respondents in Royal Prima Hospital Medan as many

as 319 people and a sample of 113 nurse respondents

using a different hypothesis test proportion of one

sample. The sample technique uses simple random

sampling through lottery. Data collection by

distributing closed questionnaires and observations

for 30 days in March 2020.

The questionnaire using the Guttman scale

consists of knowledge totalling 10 with alternative

answers (true or false) grouped (good = 2 and not

good = 1), attitudes of 10 questions (agree and

disagree) categorized (positive = 2 and negative = 1),

roles PIC 15 statements (yes and no) are grouped

(support = 2 and less support = 1). Observation of the

completeness of facilities and infrastructure with a

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checklist of 7 items, alternative answers available and

absent, consisting of: sink, liquid soap, paper towels,

antibacterial liquid, free of inappropriate equipment,

bins, and posters are grouped (complete = 2 and

incomplete = 1). Observation of hand washing

hygiene 5 moments and 6 steps are grouped (obedient

= 2 and disobedient = 1). Before the data was

processed, the instrument validity and reliability tests

were performed.

The results of the validity test obtained the value

of the calculated r coefficient in the range 0.472-

0.913 is greater than r table, (0.361), it is assumed that

the data is normally distributed. Cronbach alpha value

count 0.929, 0.950, 0.950, 0.955, 0.902 and 0.854

greater than 0,700 (determination), it is assumed that

the questionnaire is said to be reliable.

After the data is collected, it is processed by

collecting, checking, coding, entering and processing.

Furthermore the data were analyzed through

univariate (descriptive), bivariate with chi square and

multivariate tests using multiple logistic regression

tests at the 5% level. The Research procedure is

shown in Figure 1.

3 RESULTS AND DISCUSSION

Analysis of the research questionnaire based on the

category is dummy (2 groups) with a mean or average

= 1.5, where the variable above the average is

knowledge (1.54), the role of PPI (1.58), while below

the average is the attitude variable about hand

washing hygiene (1.45%), completeness of facilities

and infrastructure (1.44) and compliance with the

application of hand washing (1.35%). Measurement

results of the research variable questionnaire. The

results of data analysis are described as follows.

3.1 Univariate Analysis

Respondents with good prioritization knowledge

(54%), being negative about washing hands (54.9%),

supporting PIC's role (58.4%), incomplete facilities

and infrastructure (55.8%) and poor compliance with

hand washing (64) , 6%).

Figure 1: Scheme of Research Procedure.

3.2 Bivariate Analysis

In Table 3, the results of the bivariate analysis explain

the variables of knowledge (0.006), attitude (0,000),

the role of PIC (0,000) and the completeness of

facilities & infrastructure (0.002) having a p value

less than 0.05. This means that the knowledge,

attitude, role of PIC and the completeness of facilities

& infrastructure are related to compliance with hand

washing.

Table 2: Distribution of Research Variables.

Knowled

e n %

52 46,0

Goo

61 54,0

Attitude

ative 62 54,9

Positive 51 45,1

Role of PIC

suppor

47 41,6

Suppor

66 58,4

Facilities &

infrastructure

n %

ot Complete 63 55,8

Complete 50 44,2

Compliance washing

hands

ot Obedien

73 64,6

Obedien

40 35,4

Personnel Characteristics and Comprehensiveness of Hospital on Handwashing Compliance

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3.3 Multivariate Analysis

Table 3, Multivariate analysis results explain the

variables of knowledge (OR 5.149; p 0.003), attitude

(OR 5.176; p 0.002), the role of PIC (OR 6.156; p

0.002) and the completeness of facilities &

infrastructure (OR 3.293; p 0.017) p was smaller than

0.05. This means that the knowledge, attitude, role of

PIC and the completeness of facilities and

infrastructure have a positive effect on the

compliance of nurses' washing hands. Based on the

OR value, the PIC role variable was 6.156, which

means that the support role of the PIC tends to 6.156

times that nurses obey wash their hands rather than

the role of PIC less supportive.

Table 3: Bivariate and Multivariate Analysis Results.

Variables Bivariat

Multivariat

Knowledge

0,006 5,149 0,003

Attitude

0,000 5,176 0,002

Role of PPI

0,000 6,156 0,002

Infrastructure

0,002 3,293 0,017

Based on the research results in the table 3, the

findings can be analysed as follows. The relationship

of knowledge to nurse compliance in the application

of hand washing. There was a link between

knowledge and compliance with the application of

hand washing. Based on the OR value of 5.149 which

means that the support role of PPI tends to 6.156

times nurses obediently wash their hands rather than

the role of PPI is less supportive.

In line with the results of Khairiah's research

(2012); Ananingsih and Rosa (2016) explained that

knowledge influences the level of compliance of

nurses in using personal protective equipment

including washing hands. The minimal moment of

hand washing is caused partly by the lack of

knowledge about the importance of hand washing and

hand washing techniques. Other similar studies by

Karadag (2016); Jemal (2018); White (2019); and

Gon (2020) state that knowledge influences the

hygiene of the hands of health workers. In the study

it can also be explained that nurses with good

knowledge are more obedient in washing their hands.

However, it is also possible for nurses who have good

knowledge but are not compliant to apply good hand

washing due to busyness or workload that is quite a

lot so that without deliberate neglect of washing

hands before and after touching patients.

3.4 Attitudes of Hand Washing

There was a relationship between attitudes towards

compliance with the application of hand washing.

Based on the OR value of 5.176 which means that a

positive attitude tends to 5.176 times the nurse

submissive to washing hands rather than the negative

attitude.

A similar study by Ernawati (2014) said nurses

before and after providing health services to patients,

nurses have not complied with hand washing in the

inpatient room. Karadag (2016) said that moderate

perceptions and beliefs in nurses and students can

improve hand hygiene to avoid infectious diseases.

To increase nurses ability to apply hand washing, the

head of the Inpatient Installation instructs each head

of the room to reprimand the nurse who is not

compliant to wash hands. In addition, learning models

need to be carried out through a 5-moment hand

washing campaign and 6 steps of hand hygiene

throughout the inpatient room held every 6 months.

3.5 Role of PPI on the Application of

Hand Washing

It was obtained a link between the role of PIC on

compliance with the application of hand washing.

Based on the OR value of 6.156 which means that the

role of PIC that supports tends to 5.176 times nurses

obediently wash their hands. From the role of PIC

was less supportive as a dominant factor because the

OR value was greater than other variables. According

to Boyce and Pittet (2011) that nurses in hospitals

have not complied with the precautions of HAI

influenced by the provision of

Educational activities or training has not been

continuous as a form of PIC's role.

The role of PIC in improving nurses' ability to

apply handwashing hygiene through training

activities. Farhaoudi's research (2016) explains that

ongoing training and education can affect nurses hand

hygiene compliance. In this study also explained that

nurses stated that the role of PIC was supportive so

that it could cause nurses to obediently wash their

hands. However, there were nurses who stated that

the role of the PIC committee was supportive, but

nurses did not obediently wash their hands. These was

because nurses have attended training so that

understanding and response to hand hygiene

appropriately with 6 stages. The need for a hospital

management to implement training for nurses who

have not yet attended training, especially a new

nurses.

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3.6 Facilities and Infrastructure

There was a correlation between the completeness of

facilities and infrastructure to the compliance of the

application of hand washing. Based on OR value of

3,293 which means that complete facilities and

infrastructure tend to be 3,293 times nurses

obediently wash their hands rather than incomplete

facilities and infrastructure. A similar study by Boyce

and Pittet (2011) states that one of the obstacles in

non-compliance with hand washing is the difficulty

of accessing a handwashing area or other supplies

used for washing hands. Ease of accessing supplies of

tools for washing hands, sinks, soap or alcohol jell is

very important to make optimal compliance

according to standards.

Other research was conducted by Shobowale

(2016); and Kupfer (2019): stating the availability of

hand washing facilities or the ease of gaining access

to hand washing affects the cleanliness of hand

washing.

The results of these observations can explain that

PIC's efforts to provide handwashing equipment such

as washbasins have not been optimal, so that the

completeness of hand washing facilities was

incomplete due to PPI supervision in monitoring

nurses who in charge of providing hand washing

facilities in the sink. This factor can prevent nurses

from doing hand washing of 5 moments and 6 stages

which recommended by the hospital.

The availability of complete facilities in the sink,

can’t guarantee the implementation of 5 moments

running well. Facts in the field, there were nurses who

have not washed their hands in accordance with the

SOP in the hospital. The need to monitor the

performance of nurses implementing hand washing

by placing Closed Circuit Television (CCTV) in each

inpatient room to assess and monitor the hand

washing program.

4 CONCLUSIONS

Statistically the individual characteristics (knowledge

p = 0.003 and attitude p = 0.002), the role of PPI (p =

0.002), and the completeness of facilities and

infrastructure (p = 0.017) correlate to the compliance

of handwashing nurses. It is recommended that

hospital management increase nurses' awareness

through socializing 5 moments with 6 stages and

completing facilities and infrastructure and applying

administrative sanctions or verbal reprimands to

health workers if 3 times are not compliant.

REFERENCES

Ananingsih P.D., & Rosa E.M. 2016. Kepatuhan 5 Momen

Hand Hygiene pada Petugas di Laboratorium Klinik

Cito. Yogya-karta. Jurnal Medicoeticolegal dan

Manajemen Rumah Sakit, 5 (1):16-24.

Boyce J.M., & Pittet D. 2011. Guideline for Hand Hygiene

in Health-Care Settings. Morb Mortal Wkly Rep.

Centers for Disease Control and Prevention (CDC), 2014.

HAI’s Data and Statistics. Diperoleh di:

https://www.cdc.gov/hai/surveillance/index.html.

David De Wandel, S.L. 2010. Behavioral Determinants of

Hand Hygiene Compliance in Intensive Care Units,

http://ajcc.aacnjour nals.org/content /19/ 3/230.

Ernawati. 2014. Penerapan Hand Hygiene Perawat di

Ruang Rawat Inap Rumah Sakit. Jurnal Kedok-teran

Brawijaya, 28(1): 2014.

Farhoudi F., Dashti A.S., Davani M.H., Ghalebi N., Sajadi

G., Taghizadeh R. Impact of WHO Hand Hygiene

Improvement Program Implementation: A Quasi-

Experimental Trial. BioMed Research International.

Volume 2016, Article ID 7026169, 7 pages.

http://dx.doi.org/10.1155/2016/7026169

Gon G., et al. (2020). Behavioural Determinants of Hand

Washing and Glove Recontamination before Aseptic

Procedures at Birth: A Time-and-Motion Study and

Survey in Zanzibar Labour Wards. International

Journal of Environmental Research and Public Health.

17, 1438; doi:10.3390/ijerph17041438.

Jemal S. 2018. Knowledge and Practices of Hand Washing

among Health Professionals in Dubti Referral Hospital,

Dubti, Afar, Northeast Ethiopia. Hindawi. Advances in

Preventive Medicine. Volume 2018, Article ID

5290797, 7 pages.

https://doi.org/10.1155/2018/5290797.

Karaaslan, et all. 2014. Compliance of Healthcare workers

with Hand Hygiene Practices in Neonatal and Pediatric

Intensive Care Units: Overt Observation. Interdis-

ciplinary Perspectives on Infec-tious Diseases.

Karadag M., Iseri O.P., Yildirim N., Etikan I. 2016.

Knowledge, Beliefs and Practices of Nurses and

Nursing Students for Hand Hygiene. Jundishapur J

Health Sci. 8(4):e36469.

Kupfer T.R., Wyles K.J., Watson F., Ragione R.M.L.,

Chambers M.A., Macdonald A.S. 2019. Determinants

of hand hygiene behaviour based on the Theory of

Interpersonal Behaviour. Journal of Infection

Prevention. 20(5):232–237.

Nirbita A., Rosa E.M., Listiowati E. 2017. Faktor Risiko

Kejadian Infeksi Daerah Operasi pada Bedah Digestif

di Rumah Sakit Swasta. Kes Mas: Jurnal Fakultas

Kesehatan Masyarakat. 11(2): 93~98.

Perdalin. 2010. Pedoman Managerial Pencegahan dan

Pengendalian. Infeksi di Rumah Sakit dan Fasilitas

Kesehatan Lainnya, Jakarta.

Pratama B.S., Mulyatim K., and Kasil R. 2015. Faktor

determinan kepatuhan pelak-sanaan hand hygiene pada

perawat IGD RSUD dr. Iskak Tulungagung. Jurnal

Kedokteran Brawijaya, 28(2).

Personnel Characteristics and Comprehensiveness of Hospital on Handwashing Compliance

219

Sands M., Aunger R. 2020. Determinants of hand hygiene

compliance among nurses in US hospitals: A formative

research study. PLoS ONE 15 (4): e0230573.

https://doi.org/10.1371/journal.pone.0230573

Shobowale E.O., Adegunle B., Onyedibe K., 2016. An

assessment of hand hygiene practices of healthcare

workers of a semi-urban teaching hospital using the five

moments of hand hygiene. Nigerian Medical Journal.

57(3): 49-54.

Turnip, A., Andrian, Turnip, M., Dharma, A., Paninsari, D.,

Nababan, T., Ginting, C.N., 2020. An application of

modified filter algorithm fetal electrocardiogram

signals with various subjects, International Journal of

Artificial Intelligence, vol. 18, no., 2020.

White S., Thorseth A.H., Dreibelbis R., Curtis V. 2020. The

determinants of handwashing behaviour in domestic

settings: An integrative systematic review.

International Journal of Hygiene and Environmental

Health. 227 (113512).

Wijaya, C., Andrian, M., Harahap, M., Turnip, A., 2019.

Abnormalities State Detection from P-Wave, QRS

Complex, and T-Wave in Noisy ECG, Journal of

Physics: Conference Series, Volume 1230, (2019)

012015. doi:10.1088/1742-6596/1230/1/012015.

World Health Organization (WHO). 2014. Hand Hygiene:

Why, How & When?. Diperoleh di:

http://webcache.google

usercontent.com/search?q=cache:axFelv

MWDPgJ:www.who.int/gpsc/5may/Hand_Hygiene_

Why_How_and_When_Brochure.pdf+&cd=12&hl=en

&ct=clnk&gl=id.

Zhao Q, Yang MM, Huang Y-Y, Chen W. 2018. How to

make hand hygiene interventions more attractive to

nurses: A discrete choice experiment. PLoS ONE

13(8): e0202014. https://doi.org/

10.1371/journal.pone.0202014.

HIMBEP 2020 - International Conference on Health Informatics, Medical, Biological Engineering, and Pharmaceutical

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