Hand hygiene is the cornerstone of infection control in hospitals. However, compliance with hand hygiene recommendations, including among medical students, has been difficult to achieve. This review examines the factors that contribute to poor hand hygiene practices among medical students and presents evidence-based strategies to mitigate risks. It highlights factors other than the lack of knowledge, including convenience, and behavioral preferences. Predicated on the assumption that factors apart from knowledge influence hand hygiene compliance, it recommends interventions such as clinical scenarios and reminder mechanisms. By adopting these strategies, healthcare workers can create a safer environment.
Hand hygiene is the single most significant practice in the prevention of infection transmission in hospitals 1. However, the literature has shown that the practice of hand hygiene (HH) is not upheld even amongst healthcare professionals. Additionally, the presence of medical students in wards also raises concern about their potential impact on infection control practices, which enshrines the significance of educating medical students on HH practices. Currently, most institutions adopt traditional teachings of HH practices, which are factual, and classroom- based, contrary to the recommendations of the WHO calling for “multifaceted and multimodal” promotion programmes. In light of this issue, the present review examines the literature and identifies the factors contributing to poor HH practices among medical students, highlighting evidence-based interventions in the correction of these deficiencies.
One of the contributing factors to suboptimal disease control by medical students in ward is the low levels of hand hygiene compliance. Concomitantly, the natural response to poor HH compliance in ward is reinforcement through courses. However, a comprehensive review of the factors influencing HH uptake reveals that knowledge of HH, while amendable through intensive trainings and infection control courses, is not the most significant factor. This section argues that factors alternative to knowledge of HH practices are more dominant contributors to suboptimal infection control.
During a one-year observation study by Birnbach and colleagues, they observed third- and fourth-year medical students, who had prior participation of annual patient safety course, as they entered two intensive care units (ICUs) a teaching hospital. They found that 150 medical students failed to perform hand hygiene on entry [2]. On further questioning, the most cited reasons by male students were inadequate time and lack of role models.2 On the other hand, females cited barriers such as dry or cracked skin (34.2%). Thus, even if students have been educated on the need for hand hygiene, compliance remains low. This suggests the need to address factors other than knowledge of hand hygiene to promote its compliance.
Another measure that may promote the uptake of hand hygiene practices includes speaking-up behavior. A study by Bushuven investigated into the cognitive bias in hand hygiene among German-speaking medical students. It found that the practice of speaking-up where hand hygiene practices have been omitted was seldomly done and was especially rare when the error was committed by persons of higher hierarchical positions. Similarly, Doyle found that most medical students (85%) found it difficult to question authority practices.3 Bushuven also found that the lack of consequence for breaking hygiene rules deter its widespread adoption.4 . Therefore, hierarchical barriers and medical team factors can inhibit the collective adoption of good HH practices.
Furthermore, covariate analysis has found that factors other than knowledge are strong predictors of poor HH practices. Erasmus investigated the correlates of HH compliance among final year medical students by following 322 medical students of the Erasmus Medical center over a one-year period.5 Measuring behavioral factors using questionnaire based on the Theory of Planned Behavior and Social Ecological Models, it found that the behavioral model explained up to 40% of the variance in compliance, corroborating the finding that HH compliance was dependent on various behavioral factors.5 This includes attitudes, which was defined as the perceived outcomes of their actions, and self-efficacy, which is the accessibility of HH practices at ward. Surprisingly, self-reported compliance was not correlated with knowledge and risk perception.5 Likewise, in Kaur’s study, favorable feedback garnered from interviewed medical students after participation in a scenario-based teaching activity.6 . Students preferred the reinforcement of good HH practices through repetition at different stages of their degree in scenario-based teachings.6Coupled with Erasmus’s findings, this corroborates that targeting medical students’ behavior should refocus on factors other than merely factual knowledge of procedures.5
Having established the role of scenario-based teachings in place of classroom teaching, the following section delves into the evidence-based interventions shown to be effective among medical students
There is strong evidence for the advantage of clinical scenarios in improving HH uptake among medical students, and few studies even suggest that it may be superior to traditional teaching. Calabro designed a cohort study to determine the effectiveness of customized interventions of infection control among 200 second-year medical students in the southwestern region of the United States.7 The intervention comprised demonstration of infection control procedures with two clinical scenarios. It found a significant increase in posttest scores of HH upon the intervention.7 Additionally, clinical simulations with peer role-plays evidently promotes improvement in HH practices. Kasai’s cohort study recruited 75 students in a COVID-19 infection control education program.8 74 students agreed to semi-structured focus group interviews to discuss the advantages of simulations and lectures on clinical education for COVID-19.8 Upon analysis, the benefits of clinical simulations into various categories, but importantly, it found that the self-reflective component of simulations help to reinforce good HH practices among medical students.8
On the other hand, some may argue that clinical scenarios require manpower to set up and can be cost ineffective. Yet, whether computer-assisted teaching could supersede traditional teaching remains uncertain. A study of this question by Bloomfield attempted to incorporate audiovisual media in the teaching of hand hygiene. (Bloomfield, Roberts and While 2010). It compared computer-assisted learning with traditional face-to-face methods through a two- group randomized-controlled design (N = 242) (Bloomfield, Roberts and While 2010). The intervention group had exposure to an interactive, self-directed computer-assisted learning module, versus the control group which received didactic teaching by an experienced lecturer (Bloomfield, Roberts and While 2010). The 5-month study included the two times assessment of knowledge and handwashing skills at four selected timepoints (Bloomfield, Roberts and While 2010). While knowledge scores had significantly improved from baseline in both groups, no significant differences were detected in their scores.
Likewise, skill performance scores did not significantly differ at the 2-week follow-up. Even though the intervention group achieved significantly higher scores at the two-months follow-up, the impact of this finding is weakened by the attrition rates at the timepoint. Therefore, the study suggests that while computer- assisted learning module may improve the theoretical and practice knowledge of HH in nursing students, it is not shown to be more effective than traditional face-to-face teachings. There is a paucity of studies that compare computer-assisted learning module and clinical scenario.
Apart from scenario-based teaching, the provision of educational materials also improve adherence via reminder mechanisms. Mechanisms including the provision of gloves near a working area, posters, and supplying more hydroalcoholic solution dispensers, improve the long-term (by definition, of at least four months) compliance to HH guidelines, as demonstrated by numerous trials.9-11 Ho et al performed a cluster-randomized controlled trial among healthcare workers in long-term care facilities. Through observing 11,699 HH opportunities, which were defined as instances in which HH is required as per WHO recommendations, it found that a promotion program containing the WHO multimodal strategy significantly promoted HH practices among both arms.10 Such a strategy included multimodal educational resources including HH posters and reminders, a health talk and video clips.10 Similarly, Martos-Cabrera et al performed a meta-analysis which included 17 clinical trials and a population of 5747 nurses and nursing students.9 It found that strategies such as reminder sounds, videos, practical simulation, and audiovisual media significantly increased HH compliance.9 As a result, educational materials via multimodal reminder mechanisms significantly improve the uptake of HH practices among healthcare workers.
In conclusion, this review identified factors other than knowledge deficiencies that hinder the compliance of HH practices among medical students. This cluster of factors varied across studies, but commonly cited ones include convenience, intolerance of a speak-up culture and behavioral factors. After identifying the factors, this study also recommended scientifically proven interventions including clinical scenarios and reminder mechanisms. By implementing these evidence-based strategies, hospitals can promote a good HH culture among medical students and safeguard the health of patients.
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