Florence Nightingale and Hand Hygiene

Terry N

Florence would be amazed at the bright, shiny hospitals of today – little does she know that the lessons she taught about cleanliness and sanitation still are not being used. A hospital holds an amazing appearance of cleanliness however that is just a facade. Once Florence can see the running hot/cold water, availability of soap, alcohol gel and gloves; she would think that healthcare providers would use these easily obtained items routinely to keep their hands clean between patients and care tasks. The sad truth is today’s healthcare providers rarely perform hand hygiene routinely. According to the Centers for Disease Control (CDC), healthcare providers clean their hands half of the times they should.

During the Crimean War, Florence knew that cleanliness was vital to her patient’s health. Yet today, 1 out of 20 hospitalized patients acquire an infection from healthcare providers ⁽¹⁾. Florence would ask, “How can that be?”.

As an RN, how do I answer that question?

Looking back, my usage, failed to follow Florence’s basic principles. Oh, I used all the same excuses that I hear from my teammates now, when I observe them not performing hand hygiene. Most are the same, such as too little time, too rushed and I know I should. I am ashamed to admit this and look to all healthcare providers for the answer to this public health crisis. What is preventing us from following Florence’s example?

Florence’s solution to this disgraceful lack of basic patient care would be ...

Just do it! When she saw the unsanitary conditions, she began scrubbing and cleaning. Thinking about it, I would have to agree, just perform hand hygiene as we were taught. That brings up the question, is there enough emphasis on hand hygiene in healthcare education? We all received hand hygiene education, however, did our educators, preceptors and mentors encourage us and expect us to properly perform hand hygiene, or were they just as lax as everyone else.

Do we need re-education?

Can re-education change hand hygiene practices? Studies show that initially after re-education, there is an improvement in hand hygiene performance. Can this initial improvement be sustained? If so, how?

Another factor to consider is healthcare providers' willingness to change. Most people are ambivalent to change. Yes, we want to or need to change however something prevents us from changing. A good example, new year’s resolutions. How do we get past this natural ambivalence and make a lasting change to improve our performance?

Providers can be “forced” to perform hand hygiene by implementing punitive consequences. This is management giving consequences to staff unwilling to follow hand hygiene policies. In a world with a provider shortage, penalizing providers is not going to increase retention or on-boarding of new staff. Can you force change?

Wake-up call

At times, hand hygiene supplies have been lacking due to the covid pandemic. This should be a wake-up call to all facilities and providers for the need to maintain a “what if” supply, ensuring that providers have what they need when they need it. This lack of adequate supplies only increases providers’ reluctance to use the available supplies and creates poor habits for the future.

Patients also need to be involved in hand hygiene

Just as Florence recruited patients to help clean the hospital and improve sanitation. Patients today need to be involved in assuring that they and providers are performing hand hygiene. Patients need to feel free to ask a provider to perform hand hygiene prior to giving them care. This will give patients a sense of self-determination and remind providers of the importance of hand hygiene.

Last, but probably the most important consideration is ...

... time.

Providers feel pressured to get more done with less. This constant need to rush, forces providers to take short cuts, ignore policies and go against training just to get through the workday. Florence would be amazed and saddened at all the demands placed on a nurse in one work shift. How far we have come from just doing basic patient care such as hand hygiene? What do we need; more staff, nurses being nurses, job requirements?

Florence led nursing toward better patient care

Due to healthcare’s "do more with less attitude", many of her principles have been pushed to the side, just so the minimum can get done, so a patient might get well. Hand hygiene is one of those principles that is ignored/pushed aside by providers. The result is increased patient infections and deaths from something so simple as washing your hands. There are still many challenges to improve hand hygiene performance and no easy solutions. Florence can be our guide and mentor in making the changes required to ensure that all providers perform hand hygiene and improve patient outcomes.