Main Points

• Adherence of health professionals to both hand hygiene and isolation precautions are vital for their protection against nosocomial infections.

• Infections are the second leading cause of mortality in patients undergoing hemodialysis in dialysis units so that infection risks should be reduced in these units.

• High patient turnover may decrease the adherence to hand hygiene and isolation precautions in dialysis units. Insufficient information about the isolation needs of patients that are admitted to dialysis units may adversely affect infection precautions.

Introduction

Hand hygiene and adherence to isolation precautions are the common interventions to reduce the risk of disease transmission in a health care center (1,2). Isolation precautions may be grouped into standard precautions and the precautions for specific patient groups (3). Standard precautions refer to precautions that may be applied to all patients regardless of diagnosis or infection. These precautions are taken to eliminate risks that can be transmitted via blood, blood products or body fluids (3,4). Adherence of health professionals to both hand hygiene and isolation precautions are vital for their protection against nosocomial infections (2). Existing studies have reported that adherence to hand hygiene is affected by a number of factors, including, personal characteristics and professional experiences of health professionals, workload, lack of and distance to hygiene equipment, inadequate knowledge on hand hygiene and patient turnover (5,6). On the other hand, studies on the adherence to isolation precautions reported conflicting findings in different countries, which may be caused by the level of development and working conditions in different countries, the number, experience and education levels of health professionals, facilities of health centers, and the health and education policies (2,3,7-11).

Infections are the second leading cause of mortality in patients undergoing hemodialysis in dialysis units so that infection risks should be reduced in these units (12). During a working day, patients from different units are admitted to the dialysis units and are transferred back to their units or discharged after treatment. High patient turnover may decrease the adherence to hand hygiene and isolation precautions in dialysis units. Insufficient information about the isolation needs of patients that are admitted to dialysis units may adversely affect infection precautions. Weaker immune system of dialysis patients increases the risk of transmission for both the patients and health professionals. At this point, adherence to hand hygiene and isolation precautions become even more important. Due to these reasons, this study aims to analyze the relationship between the hand hygiene beliefs and practices and the adherence to isolation precautions in healthcare professionals working in dialysis units. Within this context, the study aimed to answer the following questions:

1. What is the level of adherence to isolation precautions in dialysis professionals?

2. What is the level of hand hygiene beliefs in dialysis professionals?

3. What is the level of hand hygiene practice in dialysis professionals?

4. Is there a relationship between hand hygiene beliefs and practices of dialysis professionals and their adherence to isolation precautions?

Material and Methods

Objectives

This study aimed to evaluate the relationship between the hand hygiene beliefs and practices of dialysis professionals and their adherence to isolation precautions.

Research Design

The study had a descriptive-correlational design.

Population and Sampling

Healthcare professionals working in dialysis units in Turkey and Northern Cyprus constituted the population. Snowball sampling technique was used to determine the sample, which included 127 nurses and hemodialysis technicians that could be accessed online after obtaining the approval of Ethical Committee of Eastern Mediterranean University (ETK00-2022-0238/02.11.2022). Nurses and dialysis technicians working in dialysis centers who volunteered to participate in the study were included in the study.

Data Collection Tools

Descriptive information form, compliance with isolation precautions scale (CIPS), hand hygiene beliefs scale (HHBS) and hand hygiene practices inventory (HHPI) were used for data collection.

Descriptive Information Form

The form was prepared by the researchers in line with the literature and asked 18 questions on age, gender, marital status, education level, education on isolation precautions and hand hygiene, problems with access to hand hygiene equipment and knowledge of five indication rules of CDC (2,3).

CIPS

CIPS was developed by Tayran and Ulupınar (13) and comprised 18 items in four subscales, namely, route of infection, practitioner-patient safety, environmental safety and hand-hygiene/glove use. Items were scored on a 5-point Likert scale. Possible scores ranged from 18 to 90, with higher scores indicating higher level of compliance with isolation precautions. Cronbach’s alpha of the original scale and our study were 0.85 and 0.90, respectively (13).

HHBS

HHBS was developed by Thea van de Mortel (2009) and adapted to Turkish by Karadağ et al. (5)  The scale had 22 items in two subscales, namely, hand hygiene beliefs and importance of hand hygiene. Items were scored on a 5-point Likert scale. Possible scores ranged from 22 to 110, with higher scores indicating more positive beliefs about hand hygiene. Cronbach’s alpha of the Turkish version of HHBS and our study were 0.80 and 0.75, respectively (5).

HHPI

HHPI was also developed by Thea van de Mortel (2009) and adapted to Turkish by Karadağ et al. (5). The inventory has 14 items, which were scored on a 5-point Likert scale. Possible scores ranged from 14 to 70, with higher scores indicating that hand hygiene is always practiced. Cronbach’s alpha of the Turkish version of HHPI and our study were 0.85 and 0.90, respectively (5).

Ethical Considerations

Approval of Eastern Mediterranean University Ethical Committee was obtained (ETK00-2022-0238/02.11.2022). Before data collection, voluntary informed consent in accordance with the Declaration of Helsinki was obtained.

Statistical Analysis

SPSS version 26.0 was used for data analysis. Mean, standard deviation and minimum and maximum values were used for numerical variables. Number and percentage were used for categorical variables. Frequency analysis was used for descriptive data on nurses and hemodialysis technicians. Descriptive statistics were used to present data on the scores obtained from CIPS, HHPI and HHBS. Pearson’s correlation analysis was used to analyze the correlation between the scores obtained from the scales and subscales. Statistical significance was set at p<0.05.

Results

Findings About Descriptive Characteristics and Practices of Isolation Precautions and Hand Hygiene

Table 1 presented descriptive characteristics. Accordingly, 92.1% were female, 47.2% had an associate degree or below, 51.2% were nurses, and 33.1% worked at a state hospital. The mean length of professional experience, experience in a dialysis center and experience in the current health center were 12.8±10.67, 8.46±8.36 and 3.02±1.74 years, respectively.

Table 2 presented data on isolation precaution and hand hygiene practices. Accordingly, 55.1% received in-house education on isolation precautions, 96.9% reported the existence of visual orders about hand hygiene and isolation precautions in the unit and 97.6% evaluated the isolation status of admitted patients from different units. Besides, 92.9% of the participants expressed that they knew the isolation precaution visuals, 40.9% stated that their units employed the isolation methods of contact, droplet and respiration, 57.5% did not experience any problems during isolation precautions, but 81.9% had problems in access to hand hygiene equipment. Finally, 74% of the participants stated that they adhered to hand hygiene after exposure to body fluids.

HHBS, HHPI and CIPS Scores

Table 3 presented data on the scores obtained from the HHBS, HHPI and CIPS. Accordingly, the mean score obtained from the HHBS and its subscales of hand hygiene belief and importance of hand hygiene were 96.19±8.1, 31.48±4.8 and 64.68±4.9, respectively. The mean score obtained from the HHPI was 62.72±5.29. Finally, the mean scores obtained from the CIPS and its subscales of route of infection, practitioner-patient safety, environmental safety and the hand-hygiene/glove use were 74.72±12.57, 22.16±4. 25.58±4.59, 14.43±2.97, and 12.56±2.43, respectively.

Correlation between HHBS, HHPI and CIPS Scores

Table 4 presented the correlation between the HHBS, HHPI and CIPS. Accordingly, there was a positive and statistically significant correlation between the HHBS, CIPS and its subscales of route of infection, practitioner-patient safety, environmental safety and hand-hygiene/glove use (p<0.05). There was also a positive and statistically significant correlation between the scores obtained from the hand hygiene belief subscale of HHBS and the CIPS and its subscales (p<0.05). Besides, we found a positive and statistically significant correlation between the hand hygiene subscale of the HHBS and the CIPS and its subscales (p<0.05). Finally, we found a positive and statistically significant relationship between the HHPI and the CIPS and its subscales of route of infection, practitioner-patient safety and hand-hygiene/glove use (p<0.05).

Discussion

This study aims to analyze the relationship between the hand hygiene beliefs and practices and the adherence to isolation precautions in healthcare professionals working in dialysis units. The purpose of isolation precautions is to prevent the transmission of microorganisms from infected persons to patients, visitors and health professionals. As a vital element of health care, the adherence of nurses to isolation precautions is influenced by a number of factors, including adequate equipment, physical conditions and the number and qualifications of health professionals that provide care (8,10,14-17). Most of the participants of this study received in-house education on isolation, evaluated the isolation status of patients admitted from different units and knew about the isolation visuals. Additionally, 47.5% of the participants experienced difficulties during isolation practices and most participants reported that their units employed the isolation methods of contact, droplet and respiration (Table 2). Analysis of the CIPS scores revealed that the participants had a sufficient level of compliance with isolation precautions (Table 3). Analysis of the literature reveals conflicting findings. The studies of Erden et al. (2), Arli and Bakan (18), and Geçit and Özbayır (3) reported high levels of compliance with isolation precautions. On the other hand, Suliman et al. (8) found that nurses in Jordan had low levels of compliance with isolation precautions, whereas Özden and Özveren (10) reported moderate levels of compliance for Turkish nurses. These conflicting findings may be related with working conditions, availability of equipment and characteristics of healthcare professionals.

Analysis of the HHBS scores reveals that the participants had positive beliefs about hand hygiene (Table 3). Similarly, the studies of Kozik Çarıklı et al. (19), İkiışık et al. (20) and Karahan et al. (7) reported positive hand hygiene beliefs among health professionals. Besides, the mean HHPI score was 62.72±5.29, indicating high level of hand hygiene practice (Table 3). In a similar vein, Kozik Çarıklı et al. (19), İkiışık et al. (20) and Karahan et al. (7) reported high levels of hand hygiene practice.

Adherence to isolation precautions and hand hygiene are among the most important practices to prevent the transmission of disease and increase patient safety, especially in hemodialysis units (17). This study found that isolation precautions had a positive and moderate correlation with hand hygiene beliefs (r=0.43) and a positive but a weak correlation with hand hygiene practices (r=0.32) (Table 4). In other words, and increase in hand hygiene beliefs and practices of the participants meant an increase in in adherence to isolation precautions. Besides, there was a positive correlation between CPIS, HHBS and HHPI scores, indicating an increase in adherence to isolation precautions parallel to an increase in the beliefs and practices of hand hygiene. Based on these findings, we may suggest that increase in hand hygiene beliefs and practices is associated with an increase in the adherence to isolation compliances.

Study Limitations

Data on adherence to isolation precautions and the beliefs and practices of hand hygiene were self-reported.

Conclusions

The study found that health professionals working in dialysis units had positive hand hygiene beliefs and high levels of hand hygiene practice and adherence to isolation precautions. Besides, the participants with positive hand hygiene beliefs had also high level of adherence to isolation precautions. Similarly, hand hygiene practice was positively associated with adherence to isolation precautions. Therefore, further observational studies in different clinical centers may be conducted to contribute to the literature. In addition, the compliance of the nurses, who are in contact with the patient for the longest time in health institutions, to hand hygiene and isolation measures is very important in ensuring and maintaining infection control. At this point, it is recommended to plan trainings regularly by hospital infection control committees.

Acknowledgments: The authors thank the Dialysis Professionals who participated voluntarily in this study.

Ethics Committee Approval: Approval of Eastern Mediterranean University Ethical Committee was obtained (ETK00-2022-0238/02.11.2022).

Informed Consent: Before data collection, voluntary informed consent in accordance with the Declaration of Helsinki was obtained.

Peer-review: Externally peer-reviewed.

Author Contributions: Surgical and Medical Practices – A.D.Ç., S.C., F.B.; Concept – A.D.Ç., S.C., F.B.; Design – A.D.Ç., S.C., F.B.; Data Collection and/or Processing – A.D.Ç., S.C., F.B.; Analysis and/or Interpretation – A.D.Ç., S.C., F.B.; Literature Review – A.D.Ç., S.C., F.B.; Writing – A.D.Ç., S.C., F.B.

Declaration of Interests: No conflict of interest was declared by the authors.

Funding: The authors declared that this study received no financial support.