Introduction of New Theory for Hand Hygiene Surveillance: Healthcare Environment Theory

Explanation of the Six Environments of the HET

Bronfenbrenner’s five environments of microsystem, mesosystem, exosystem, macrosystem, and chronosystem, along with Troyer’s four environments of family, church, government, and work, evolved into the six environments of the HET. It seems more appropriate to use environment names that actually are representative of the environment. Bronfenbrenner’s microsystem evolved into the family environment, while the mesosystem evolved into the work environment. Troyer also advocated the use of these two environments but the HET moves these two environments into the hospital setting and while the two are exerting influence along with the other environments, they are two separate environments.

The family environment not only represents the RN’s own personal family but also the work family. The marital status of the nurse and whether or not they are a parent are influencing factors stemming from the personal family. A supportive spouse at home eases the stress and heavy workloads found in the ICUs. ICU nurses work under very intense and stressful conditions, forming a bond enabling support and cooperation between nurses to flow freely. A close-knit unit will generate a high level of teamwork with a strong sense of teamwork lending support to each nurse during times of a heavy workload and high-stress situations such as code blues. Certain situations in the hospital, such as a code blue or a patient at risk of fall attempting to get out of bed, make it difficult to achieve hand hygiene rates of 100%. It is during these times that saving the patient from dying or falling becomes the rewarded behavior while there is no consequence for not participating in hand hygiene. The patient safety culture of the hospital, especially if there is a tolerance of low hand hygiene rates, has been related to the emphasis the chief executive and administrative department place on hand hygiene and its importance, all of which influences the work culture as well (McLaws & Sax, 2017; Whitby et al., 2007).

The work environment is the actual ICU setting itself but is enlarged with the addition of all of the departments the nurses interact with on a daily basis in order to care for patients. Work environment affects the family culture through the number of shifts worked, shift hours, working weekdays or weekends, stress carried between the ICU and the home, and the need for childcare while the parent is at work. The work culture also interacts with the cultural environment of the unit. Service systems, network linkages (the infamous grapevine), political forces and the policies of the hospital, the unit worked, cultural forces, the unit work culture, the culture of patient safety at the hospital, social forces, social work values, roles played by the nurses, and professional issues such as position held (e.g., staff nurse, charge nurse, or supervisor) all play interacting roles in hand hygiene habits. The work environment also involves interactions between the nurse, the physician, and other HCWs when developing the patient’s care plan. Peer attitude also influences the work environment and the hand hygiene rates (Jimmieson et al., 2016; Pittet, Boyce, & Allegranzi, 2017; Whitby et al., 2007). The work environment directly affects the hand hygiene rates of nurses. Literature reports that an increased workload leads to decreased hand hygiene rates (Dai, Milkman, Hofmann, & Staats, 2015; Pittet, 2001, 2004).

The community environment of the HET is not found in either Bronfenbrenner’s work or in Troyer’s model. While it may be argued that the community environment is not a part of the hospital setting, there is strong literature support that the community culture is closely intertwined with hospital culture and vice versa. The hand hygiene rates in one environment will influence the hand hygiene rates in the other (McLaws & Sax, 2017; Whitby et al., 2006). Whitby et al. (2007) showed hand hygiene behavior differs on different hospital units and among different groups of HCWs, suggesting that the individual and the community each influence hand hygiene. Behaviors are transferred between the ICU and the community (McLaws & Sax, 2017; Whitby et al., 2007). Friends, extended family, school (including higher education in nursing and medical schools), public health, and outbreaks both in the community and in hospitals are all factors affecting the community environment, which is related to the hand hygiene behavior of the nurse (Whitby et al., 2007).

Patients are also brought into the hospital from the community and discharged back into the community, sometimes discharged with infections increasing the risk of cross contamination among community members which includes nurses (CDC, 2016; Donker, Wallinga, Slack, & Grundmann, 2012). During a disease outbreak in the community, patients may be hospitalized. Likewise, a nosocomial outbreak in the hospital may generate patients who are discharged back into the community colonized or still with active infection.

Bronfenbrenner’s exosystem and Troyer’s government environment became the administrative environment of the HET. The government and administrative environments involve the person being influenced but that person is usually not a part of the decision-making process. A person (nurse in the community) is influenced by local, state, and federal regulations. Although each person has the right to vote, their one individual vote seldom is the deciding factor for a given law or regulation. Likewise in the hospital, the administrative department sets policy and regulations but the nurse does not usually have a say in this. There is no choice given to the nurse whether or not he or she wants to participate in hand hygiene. The policy will call for 100% compliance of hand hygiene behavior 100% of the time by 100% of all HCWs. The administrative leaders in the hospital will include the unit managerial staff, the vice president in charge of patient care, the chief nursing officer responsible for the oversight of all nursing personal, and the chief executive officer of the hospital.

In the HET, the culture environment replaces the macrosystem of Bronfenbrenner. There are many cultures represented in the ICU setting. Each nurse has his/her own individual culture or ancestry. The cultural environment of the unit will be influenced by the ethnicities of all of the HCWs on that unit, their religious beliefs, the teamwork practices of the unit, and by the blending of all of these individual cultures into a unit culture. Added to this is a hospital culture, which is set by the CEO and administrative offices. The hospital culture affects the hand hygiene behavior of all HCWs because the hand hygiene compliance and infection rates are what a CEO and the administrative will tolerate (Jimmieson et al., 2016).

All of the unit cultures and the influence of the administrative environment combine to form the hospital patient safety culture (Pellegrini, 2017; Sammer & James, 2011). The cultural environment is also influenced by whether or not the hospital is church or faith affiliated, whether or not the hospital is for profit, and whether it is a private hospital or a community hospital supported by community funds. Also involved with the cultural environment are the invisible and unconscious aspects of culture, such as attitudes, values, beliefs, peer pressure, and norms of behavior or the inherent hand hygiene habits of the HCW (Kaufman & McCaughan, 2013; Whitby et al., 2007).

Under Bronfenbrenner’s macrosystem and Troyer’s church environment, a nurse’s religious beliefs and practices as well as the church affiliation of the hospital will resonate in the church environment of the HET. The church environment combines with the unit and hospital culture environment to also influence the nurses’ values and attitudes toward teamwork and patient safety, the overall hospital culture, organizational goals, and the mission statement. Depending on if the hospital is church affiliated or for profit will contribute an important component in determining the hospital culture and the unit culture concerning organizational values and practices, the patient population served, hospital policies, and the hospital’s position on abortion. The family, church, and community environments will all impart an influence on the decisions of the Ethics Committee.

The chronosystem of Bronfenbrenner fits under the work environment of the HET. Nurses’ behavior toward patients and their personal culture will transition as years of experience are gained. A patient response elicited from a nurse during the first year after graduation should be different from that of a seasoned nurse. A seasoned nurse will have greater observational powers, better decision-making skills, and greater management skills.

Please see Appendix A for a list of the definitions used for each of the 15 independent variables and the dependent variable of hand hygiene compliance. Although Bronfenbrenner’s theory of ecological systems theory has been tested many times, this is the first time this conceptualization of his theory in the healthcare setting has been used. The HET was born because once the environments were changed and the community environment was added, it had evolved into a unique theory that could now be utilized as a theory for the hospital setting and for hand hygiene surveillance studies. Troyer’s model of his four environments has not been identified in print. Because of the lack of an existing theory for hand hygiene studies, it was deemed important to present the HET as a unique theory that could be utilized by the infection control practitioner with a goal of better understanding the motivational drivers for modifying hand hygiene behavior among HCWs. The goal of the infection control practitioner has always been to increase hand hygiene rates in order to reduce the incidence of healthcare-associated infections. For example, understanding how age affects the rates of hand hygiene, it becomes clearer as to which age groups should be targeted for use as champions and which groups should be targeted for interventions.

In viewing all of the interactions and interplay between all of the environments that influence the nurse and those which the nurse influences, it is easy to understand why multidimensional interventions are required in order to affect hand hygiene rates. HET is presented for hand hygiene and other infection prevention compliance studies in hospital settings to provide infection control practitioners with a theory useful for explaining the hand hygiene behavior of the HCW.

Methodology for Study in Which HET Was Utilized

Institutional review board approval number: Walden University 03-09-16-0327877 and Aspire IRB, Inc. 0.29.NUR.2015C.

HET was used as the theoretical foundation for the dissertation study, Demographic Factors Associated with Consistent Hand Hygiene Adherence Among ICU Nurses (Kurtz, 2017a). The study design was a quantitative, cross-sectional, prospective, overt observational study by a single observer, who was an infection control practitioner, Certified in Infection Control (CIC), and trained in hand hygiene observation. Agreements were signed with four hospitals in Texas to be used as data collection sites with one hospital contributing two ICUs. Bed capacity ranged from less than 175 beds to two hospitals each having over 500 beds. ICU beds ranged from 20 beds to 36 beds. A convenience sample of 64 ICU registered nurses (RNs) participated in the study with an average of 13 RNs participating at each ICU (range 11–15 RNs). A total of 3,620 hand hygiene opportunities were collected from the five ICUs (range of 551–891 hand hygiene opportunities at each ICU). In order for each ICU to qualify as a stand-alone study, an individual sample size of 613 (sample size of 556 plus a 10% margin for missing data) hand hygiene opportunities was sought from each ICU. This sample size was based on a priori analysis using alpha as 0.05, effect size as 0.10 (small effect), and a power of 95%. G*Power, v. 3.1.9.2 for MacOSX, March 28, 2014, downloaded from the Heinrich Universtät Düsseldorf website was used for the calculation (Faul, Erdfelder, Lang, & Buchner, 2007, 2009; G*Power, 2013). Length of observation was calculated on 20 hand hygiene opportunities per hour, yielding 160 opportunities for 8 hours (20 × 8), and 640 opportunities in 4 days of observation (160 × 4 days). Opportunities varied greatly, from a low of 6 per hour to 71 per hour, average of 25 hand hygiene opportunities per hour.

Observation began at each ICU on Monday at 7:00 am and continued for 8 continuous hours per day until the sample size of 613 was obtained. The sample size was collected at three ICUs in 3 days, one ICU in 4 days, and one ICU in 5 days. At one ICU, 551 hand hygiene opportunities were recorded rather than the full sample size sought (556 + 10% margin = 613). Total observation period was 18 days or 144 hours. Data were collected from March 21, 2016 to August 4, 2016. Multiple nurses were observed each day, with usually 5–7 nurses being observed simultaneously. It was not possible to observe more because of the hall structure. Usually sitting in the middle of the hallway across from the middle room being observed, it was possible to observe only 2 or 3 rooms to the right and to the left. During the observation period, the observer was very visible to all of the participant nurses.

During observation, hand hygiene opportunities were recorded for each nurse participant during each room entry/room exit. Did the nurse participate in hand hygiene, yes or no? Quality of hand hygiene practice was not collected during this study. Rate was calculated as the number of positive hand hygiene opportunities over the total number of opportunities. Rates were calculated for each nurse per hour and per each day of observation. Each ICU received a report of their individual aggregated hand hygiene compliance rates. Data were then aggregated.

Individual nurses or groups of one and two were approached each morning between 6:30 am and 7:00 am and asked if they would be willing to participate in the study. Explanation of the study with opportunity to ask questions was given before verbal agreement to participate was accepted. The nurses were asked to participate, given a 15 demographic questionnaire to compete by 3:30 pm, and they were told their hand hygiene opportunities would be observed and recorded by a single observer who would be sitting in the hallway across from the entrances to their assigned rooms. Please see Appendix B for questionnaire. Nurses were provided a letter of consent for their records, but their signatures were not required since completing the 15-question demographic questionnaire signified their willingness to participate. No information other than demographic information was sought and participating nurses received no compensation. Five nurses declined the invitation to participate with one of the five self-volunteering 2 days later for a participation rate of 94%. A total of 11 missing answers on the questionnaires out of a possible 960 answers generated a missing data rate of 1.15%. Nursing demographics have been reported in other manuscripts (Kurtz, 2017b, 2017c).

Data from each questionnaire were linked to the individual RN’s hand hygiene rate before aggregation of data took place. Each nurse was requested to wear a research badge with a number matching the number on the questionnaire he or she had filled out. This number was used to record each nurse’s hand hygiene opportunities. Each of the demographic variables were assigned to one of the six environments in order to help understand how these six environments influence the hand hygiene compliance of the ICU nurse.

The variables related directly to the family environment were age, gender, marital status, and number of children. Church environment was represented by the variable spiritual affiliation. Total gross family income and whether the RN was an agency nurse or a hospital employee was related to the administrative environment. Community environment was represented by the country in which the nurse was born, the county in which the nurse graduated from nursing school, and the number of years the nurse had lived in the United States. Ancestry was associated to the cultural environment. The work environment was associated with the year of graduation from nursing school, number of years of active nursing practice, areas of previous nursing practice, and nursing degree (e.g., bachelor of science in nursing or associate degree).

Descriptive and paired-sample t-tests were used for analysis, with all the data stored and analyzed using the Statistical Package for Social Sciences (SPSS) for Macintosh (IBM SPSS Statistics version 22.0, Armonk, NY, released in 2013).

Results

The descriptive and inferential analyses of this study with the demographic variables and the hand hygiene rates have been reported elsewhere (Kurtz, 2017a, 2017b, 2017c). In this section, only how the variables and the environments interacted will be discussed.

Using a paired-sample t-test and the dependent variable of hand hygiene measured in percentage ranges, it was found that the influence of the number of children, number of years living in the United States, and age of the nurse had a statistically significant (p < .001) effect on hand hygiene rates. When the dependent variable was associated with <50% or >50% adherence, number of years of active nursing practice, number of years of living in the United States, and age of the nurse became significant (p < .001). Using the dependent variable of the actual hand hygiene rate of each nurse, gender, marital status, ancestry, spiritual affiliation, areas of previous nursing practice, gross family income, degree program (bachelor of science in nursing or associate degree), country in which nurse was born, and country from which the nurse graduated were each statistically significant (p < .001). The variable, year of graduation from nursing school, was dropped from final analysis because of the high degree of collinearity with the variable of number of years of nursing practice. The variable of hospital employee or agency nurse was dropped because of the small percentage of nurses who were represented in the agency nurse population (4.7%).

Please see Table 1 for the confidence intervals associated with the independent variables. The post hoc power analysis with an alpha of 0.05 yielded a power of 0.9999780 with an effect size of 0.100003. Being a parent was associated with increased hand hygiene but marital status was not.

In the literature, the hand hygiene rates for nurses between 21–30 years old and 31–40 years old were 41.5% and 41.1%, respectively (Sharma et al., 2011). Younger nurses today in the 20–29 years old range were born between 1987 and 1996 (in this study, this age group had hand hygiene rates of 85% when looking at hand hygiene compliance rates >50%). Nurses who are now 30–39 years old were born between 1977 and 1986 (in this study this age group were 78% compliance in hand hygiene compliance rates >50%). Nurses in the 40–49 year range now were born between 1967 and 1976 (hand hygiene rate >50% was 67%). In this study, when looking at hand hygiene compliance rates of >50%, nurses in the 50- to 69-year-old range were between 50% and 80% compliant, but no rates were recorded above 80%.

The results of this study also showed that both younger age and a shorter length of nursing practice were factors associated with higher rates of hand hygiene. Shorter lengths of time of active nursing practice can be correlated with both older and younger nurses as many individuals are now entering nursing as a second career at a later stage of their lives. One of the nurses in this study, age 61, was a recent graduate (less than 6 months) and had been working in the ICU for only a couple of months.

The community environment is also encompassed by the variables of country in which the nurse was born. In a comparison of nurses born in the United States and born in countries other than the United States, in looking at hand hygiene rates, 75% of the nurses born in the United States had a hand hygiene rate >50% and 10% had a rate >90%, while 83% of the foreign born nurses had a hand hygiene rate >50% and 25% had a rate >90%.

Because of the small sample size for each spiritual affiliation category and for the categories of ancestry, it was not possible to draw an association between the church environment, the culture environment, and hand hygiene compliance.

Pertaining to country of graduation, 94% of participants were from nursing schools within the United States and 6% were from Canada, India, and the Philippines. The small percentage of nurses graduating from other countries made it mathematically unsound to draw conclusions regarding the association of country in which nurse graduated from with hand hygiene rates.

The variables of number of yeas of active nursing practice, areas of previous nursing practice, and degree program are all reflected in the work environment. While additional years of practice constitute work experience (not only in terms of clinical expertise but also in terms of social and management skills), this variable was not shown to generate a higher hand hygiene rate.

Discussion

The family environment variable involves not only the nurse’s private family but also his or her work family. The extended work family includes all of the various departments with which nurses interact daily. Network linkages established by the nurse political forces, hospital policies, unit worked, the cultural forces of the unit (both the unit culture and the cultures of the individual nurses), the culture of patient safety set by the administration, and position held (e.g., staff nurse, charge nurse, or management staff), all interact to assert influence on the nurse’s hand hygiene behavior. In this study, age was shown to be a significant variable associated with hand hygiene compliance. These results are believed to be the results of the influences of hand hygiene during the 1970s and 1980s with greater emphasis on hand hygiene not only in the community but also through increased emphasis of hand hygiene by nursing schools and medical schools as a way to decrease infections.

Age and number of years of nursing practice can be considered important factors in the family environment as it gives the nurse a position in the family hierarchy and also a position on the unit. Nurses with longer years of nursing practice are used as mentors for nurses with less experience. However, today it can no longer be assumed that an older nurse has the greater years of practice. A nurse today who is 50 years of age may have been in practice for 30 years or may have been in practice only for the past couple of months. So it was deemed important to investigate if higher hand hygiene rates were associated with the age of the nurse or with the number of years of active practice. This study confirmed that the nurse younger in chronological age and those nurses with less years of practice had higher rates of hand hygiene compliance even though some of these nurses were in the older age brackets. As a result of the inherent training (from 1 to 10 years of age) and the increased emphasis of hand hygiene in nursing and medical school, the younger nurses of today are exhibiting higher hand hygiene compliance rates. Children born earlier, who are now the older nurses of today, did not receive this additional training and today are exhibiting lower hand hygiene rates (unless they are recent graduates).

It will be interesting to see if the increased rates that are being reported today among the younger nurse population will continue as these younger nurses age and the older nurses retire. What is being seen may be a slow cultural change. If this trend continues as the current nursing population ages, it may be that the best way to teach nurses to become 100% adherent with hand hygiene is to teach children the importance of hand hygiene.

It was also deemed important to know if the influence of being a parent would influence hand hygiene behavior. It was shown that those nurses who were parents did have higher compliance rates. This might be contributed to the increased teaching of the child, setting the example by their own increased rates, and increased awareness of the necessity of hand hygiene in the community setting.

In the administration environment, the nurse does not play an active role but experiences the influence of administrative decisions. Although nurses are, for the most part, not a part of the policy process, they are bound to comply with policies that call for 100% compliance with hand hygiene. In this study, the ICU with the highest overall hand hygiene rate had the strongest administrative and management support.

Culture is a complex issue because many different cultures coexist in a hospital setting. The culture of each individual nurse, the diversity of all of the nurses working in the ICU, and the work culture itself are all reflections of the attitudes, beliefs, and perceptions of the unit staff. Categorizing the ages of the nurses into groupings such as 20–29, 30–39, and so forth, also forms a culture, as different values and attitudes are held by different age groups, each exerting its own influence on hand hygiene behavior.

Lifetime experience, workload, individual attitudes, and support from management and team members multidirectionally affect and are affected by the work environment. Also influential is whether the nurse works the day or night shift, weekdays, or weekends. The work environment includes, as well, how the nurse interacts with other HCWs from other departments, with residents and physicians, with family members, with visitors, and with the community. A nurse coexists within the hospital and the community life. This is evidenced by the higher hand hygiene rate seen in nurses who are parents. In a work environment where there is a great deal of teamwork, nurses experience less stress. When sharing the workload, each nurse feels that there is more time to follow policy and to participate in hand hygiene.

The higher hand hygiene rates of some of the variables (age, number of children) dealing with the family environment shows influencing factors of some but not all variables found within the family environment. The administrative environment has been shown to be influential in affecting hand hygiene rates. The work environment and the community environment also were shown to influence hand hygiene. This study has also shown how each of the environments are influenced by all of the other environments and how each environment is composed of multiple subenvironments.

An opportunity is now presented to use a theory specifically designed for studying the hand hygiene behavior of the HCW. The act of hand hygiene is a simple but highly complex behavioral function influenced by multiple factors simultaneously. Understanding hand hygiene behavior through the HET environments and the bi-directional influence that each has on the others can benefit and broaden our understanding of hand hygiene behaviors and the HCW.

Limitations

Limitations in this article mostly apply to the results obtained for the hand hygiene surveillance portion of the study reported elsewhere, but are listed here for a clearer understanding of the HET application.

Opportunities for Future Research

Designed specifically for healthcare, the hospital setting, infection prevention, and hand hygiene surveillance, the HET can be used to understand the hand hygiene behavior in the ICU nurse.

With many articles advocating the use of a multidisciplinary approach to interventions to increase hand hygiene, there is a need for a theory that examines multiple environments to explain all of the interventional multidirectional influences. Nurses do not live and work in isolated environments. Their family lives are brought into the ICU and, likewise, their ICU experiences are carried back into the community. Their work family affects their hand hygiene through teamwork, peer relationships, and management influences. The church environment, the administration environment, and the community environment all influence the hand hygiene rates of nurses, with the nurse affecting each of these environments in turn. The individual culture of the nurse, the cultures of coworkers, the culture of the nursing unit, and the hospital culture of patient safety bidirectionally assert influence on the hand hygiene of the ICU nurse. Therefore, the HET model is proposed for consideration as a new theory to help explain the hand hygiene behavior of the ICU nurses. Until testing is done on an international basis, it will be unclear as to whether or not these six environments will be influential in hand hygiene compliance studies in other countries.