HAND HYGIENE COMPLIANCE AMONG NURSING

 EXPLORE HAND HYGIENE COMPLIANCE AMONG NURSING IN HEALTHCARE SETTING USING BEHAVIORAL THEORY

By Tumusiime Isaac +254712214954

 Introduction

Hand Hygiene is a broad term mentioning any hand cleansing action (WHO 2016, P.4). Hand hygiene, whether by hand disinfection or washing, remains the sole utmost significant measure to avoid nosocomial contaminations. A healthcare related infection is attained by ill people in receipt of such care and denotes the greatest recurrent adverse occurrence. Healthcare associated infection compliance is multifaceted and needs the practice of standardized measures, accessibility of diagnostic amenities and proficiency to conduct and understand the outcomes (Hand Hygiene Australia, 2016). While surveillance and compliance structures for healthcare associated infection are present in several developed nations, they are almost absent in majority of developing nations. Using the behavioural theory, I explore hand hygiene compliance among nursing in the healthcare setting in this paper. In addition, I ascertain the enablers and barriers to nurse compliance to hand hygiene, and develop behavioural theory-founded data translation intercession to grow nurses’ compliance with best practices of hand hygiene.

The behavioural theory The behavioural theory states that valuable approaches to enhance hand hygiene behaviors associate with individual opinions that stimulate the intent to execute hand hygiene. The theory points out behavioral intention determinants to include; first, the individual has faith in hand hygiene at time of such care avoids spreading of bacteria and injury of patient from heath associated infections. Second, the personal believes that supervisors, peers and patients expect and value hand hygiene compliance. Third, the individual beliefs of possession of authority over Explore Hand Hygiene Compliance Among Nursing in Healthcare Setting Using Behavioral Theory4 resources are essential to observe hand hygiene and removal of performance barriers (Bradley, 2016). Targeted motivators are indicated by the barrier, belief, and/or behavior assessment results.

Global statistics

Overall estimations show that over One point four million ill persons internationally in both developing and developed nations are infected by hand hygiene incompliance diseases at whichever time. In 2005, the World Health Organisation Patient Safety initiated the first international challenge on Patient safety to incite international action and focus on the serious patient care problem of healthcare associated infection and on the important of the compliance of hand hygiene role by healthcare personnel in reducing such contagions. According to available country or multicentre research, mutual HCAI occurrence in mixed patient populaces was seven point six per cent in developed nations (WHO Report on the Burden of HCAIs 2011, p.3). The Centre for Disease Prevention and Control of Europe assesses that about 4 million ill persons contract healthcare associated infections in the European Union annually. The sum of deaths happening as a direct result of these infections is predicted at thirty seven thousand and the infections contribute a supplementary 120 000 losses annually. In 2002, the projected HCAI prevalence rate in the US was 4.5 per cent, consistent to 9.3 contaminations for every 1200 patient-days and one point seven million affected ill persons. On average, 61 per cent of health personnel do not observe commended hand hygiene regulations and practices. Nearly 20000 health institutions in over 180 countries worldwide have preserved compliance with hand hygiene and enhancement through the Clean Your Hands crusade (WHO Healthcare, 2016). About 20 to 30 per cent of healthcare related infections are reflected to be avoidable by rigorous hygiene and control platforms. Explore Hand Hygiene Compliance Among Nursing in Healthcare Setting Using Behavioral Theory

United Kingdom

In the 1998 to 2000 in England, a nurse-ran multiprofessional researchers team of and expert clinicians aided the Department of Health initially to commission country evidencegrounded plans for averting health care-linked contaminations in country health provision hospitals and established. Even though medical personnel compliance to hand hygiene is below the country 75% target, there is continual rise in compliance to hand hygiene in healthcare staff as of 2009. Medical nurses now have compliance to hand hygiene rate of 71 per cent per 2014, just overhead the 2014 nationwide doctors-rate of 69 per cent. The problem (Justification of Study) Health care workers, when invited to estimate their compliance to hand washing regularity, have a habit of reporting a considerable higher acquiescence rate than in fact observed (Tibballs 1996, p.1). Although it is conceivable that selected providers might be merely lying about their compliance to hand-hygiene, appears additional possible that a greater amount of this inconsistency is because of worker self-deceit. Self-deception is having an erroneous idea or belief regardless of accessibility of supplementary accurate evidence, short of carrying along the identical moral inferences as modestly lying. However in the health care workers case, who have faith they are sufficiently following protocols of hand hygiene when in actual sense not, the negative costs continue stay unchanged. Self-deception is subliminal, so, abundant resistance to behaviour adjustment (Mele 2001, p. 5).

Literature Review

Behavioural practices

In 1998, researchers reviewed the dominant behavioural theories and corresponding applications in regards to the health experts in an effort to well understand ways to broaden more successful intercessions (Kretzer 1998, p.317). The researchers suggested a hypothetical basis to improve practices on hand hygiene and emphasized the significance of bearing in mind individual complexities and institutional aspects when crafting behavioural intercessions. Although such theories on behaviour and subordinate interventions have predominantly targeted individual personnel, this exercise might be inadequate to yield sustained transformation. Interventions intended to improve hand hygiene rehearsals ought to explain the different stages of behaviour collaboration.

Fuller and associates recently directed a mass randomised well-ordered pilot of a behaviourally premeditated response intercession in over 60 infirmary zones throughout Wales and in England implementing a nationwide campaign on hand hygiene. Results showed that such intervention, coupled with response to individualized action preparation, as related to routine care, formed significant and moderate sustained developments in compliance to hand hygiene (Fuller et al., 2012). Although this research indicates encouraging effects for the usage of behaviourally planned response interventions to advance compliance to hand hygiene, additional execution studies are compulsory to define the effect of intervention in diverse contexts and settings.

The interdependence of discrete factors, ecological restraints, and formal climate has to be considered in the premeditated planning and advance of campaigns on hand hygiene. Interventions to endorse hand hygiene in infirmaries ought to deliberate on variables at every such level. Numerous factors engaged in behaviour on hand hygiene comprise of attitude, intention in the direction of the behaviour, apparent social custom, perceived behavioural control, threat for infection perceived, practices on hand hygiene, role model perception, knowledge perceived, and inspiration. Factors essential for change consist of: One, the dissatisfaction with prevailing state; two, the alternatives perception, and Three, the recognition, at both individual and institutional levels, of the capacity and likeliness to transform. Though the latter suggests motivation and education, the former two require a change in system.

The Hand Hygiene in Health Care Guidelines of the World Health Organisation provides a broad scientific data review on practices and rationale for hand-hygiene in healthcare. An overall of eight hundred and seven healthcare facilities from ninety one nations submitted a completed the self-valuation framework on hand-hygiene surveys to the World Health Organisation. Amongst all these, eighty six facilities finalized the survey in 2015and 2011. It is in Malaysia that the biggest number of contributing facilities, 150 facilities, is reported in the 2015 to 2016 survey. France follows with 65 facilities and Spain with 49 facilities. In total, of the participating institutions, 30 % were established in the Europe, the biggest figure by area. The total mean tally revealed an intermediate progress level, nonetheless very near to the higher range limit, score 375, for this kind of level and near the lesser range limit for the progressive level, as the World Health Organisation HHSAF defines (WHO Report 2016, p.3). Majority of the facilities were at 87.5 %, advanced or intermediate progress levels, with 79 % at a great fraction of qualifying for the level of leadership.

Compliance

A cross-sector observational research by means of technique of direct observation was carried out in the operating ICU of a hospital to evaluate HH adherence amongst healthcare personnel and associated nurses, at their training period completion. The outcomes indicate a 78 % total compliance as required by World Health Organisation Guidelines. 63 % rate for Nurses’ adherence and 86.5 % adherence by allied staff. Patient contact Compliance before and after was 63 % and 93 % respectively. Compliance by nurses before aseptic processes was lowermost at 39%. Staffs aware of the facts before such procedures were 92 % (Shukla, Chavali and Menon, 2014).

For the five WHO indications, another observational research was piloted on hand hygiene compliance. During a patient care routine in a day shift, there was observation of healthcare workers. The researchers, with alcohol-founded disinfectants, similarly measured the HH technique of hand hygiene. An overall of seven hundred and four hand hygiene opportunities were acknowledged all through the observation timeframe. 37.0 % was the general compliance (that is 261 out of 704). Such compliance varied by duty: 41.4 % for nurses and 31.9% for doctors. With 63.6 %, HCWs seemed more declined to using water and soap in comparison to the 36.3% who preferred waterless or alcohol centred hand hygiene Devotion to practice of hand hygiene and practice of alcohol-centred disinfectant was establish as being actually low (Karaaslan et al., 2014).

Operational education packages improving hand hygiene adherence and disinfectants use may well be supportive to intensify hand hygiene compliance. Karabay 2005, p.315 notes that compliance to hand hygiene is understood more in recently employed staff and subordinate nurses, and Akyol 2007, p.431 claims that in comparison to physicians, compliance to hand hygiene is greater among nurses and supplementary Healthcare personnel. Ott & French 2009, p. 702 propose the behaviour and attitudes aimed at hand hygiene are a multifarious issue that involves the discernment of its efficiency, personnel beliefs, ideals and prevailing blockades. Defaulters must be disciplined as if they have dishonoured hospital rule in order to attain high hand hygiene compliance rates, beginning with private therapy to oral caution and ultimately a formal caution retained in such workers’ files.

Compliance enablers and barriers

By means of a behavioural theory methodology, Boscart and associates reconnoitred nurses’ professed enablers and barriers to practice of hand hygiene. Nurses paid attention on instant consequences; for instance, the nurses acknowledged their individual and family safety as central motivation source of performing hand hygiene. Similarly, they defined the significance of self-monitoring and discrete feedback to upturn their routine (Boscart et al. 2012, p.1). In the current attitudes in the direction of hand hygiene survey, doctors described recalling implementing hand hygiene and great assignment or sense of being excessively rushed as main barriers to compliance of hand hygiene. A second survey, which measured a variety of Healthcare workers comprising of nurses too, found eco-friendly barriers to compliance to hand hygiene dominant, that is, absence of soap, damaged soap distributers, and deficiency of paper rubs (Pyne 2012, p.4).

Another barrier is gaps in educational and infection governance training amongst nurses. Supplementary barriers specific to nurses postulated comprise of the perception amongst nurses that compliance is way better than it truly is (Tibballs 1996, p.1); the growth of a added cavalier arrogance in the direction of infection governance as clinical experience rise, with a related compliance rates drop (Berhe et al. 2005, p.13); the absence of encouraging role models  amongst nurses engaged in the healthcare team; and, the resident hospital philosophy on safety of patients.

Conclusion

I detail the necessary solutions and recommendations to nursing hand hygiene compliance by various studies and institutions concerned with healthcare associated infection and hand hygiene.

Education and training

All healthcare personnel require comprehensive training or education on the worth of hand-hygiene, the “My 5 Moments for Hand Hygiene” policy and accurate hand rub and wash procedures (WHO 2016, p.16). By broadcasting clear communications, exclusive of personal interpretations, with a user-positioned uniform approach, such education or training must aim at inducing cultural and behavioural change and ensuring that competency is innate and preserved amongst the entirety of staff in regards to hand hygiene. Education is an essential element of strategy which incorporates sturdily with every other indispensable strategy apparatuses. Certainly, without suitable training it is improbable the change in system will achieve change in behaviour with the authentic adoption of alcohol founded hand rubs and unrelenting development in compliance to hand hygiene. Feedback and evaluation especially about native compliance results and rates from the test on knowledge trigger courtesy to the education concepts targeted. Furthermore, majority of reminders types are established to call consideration to main messages on education. Lastly, construction of a genuine and strong organization safety philosophy is fundamentally related to operative educational intercessions.

Hand hygiene feedback and monitoring

Evaluation in addition to recurrent observing of a variety of pointers imitating handhygiene practices and infrastructures, healthcare executive managers and employees acquaintance and awareness of the healthcare related infection problem; and the prominence of hand-hygiene at institution of healthcare, is an essential factor of any positive campaign on hand-hygiene (WHO, 2016). The World Health Organisation established a multimodal mode of hand-hygiene enhancement plan tools for feedback and evaluation. Additional, the organisation urbanized the Framework for Hand Hygiene Self-Assessment, an instrument to find a condition examination and hand hygiene practices score and advertising in a separate facility of healthcare, conferring to a group of indicators imitating the World Health Organisation’s Multimodal Hand Hygiene Improvement Strategy (WHO HHSF, 2016). Repeated practice of the Framework allows progress documentation over a time period.

The Hand Hygiene Self-Assessment Framework is presently used in numerous health care establishments internationally to track and assess advancement in improvement of handhygiene. The framework offers a methodical situation examination of hand-hygiene promotional, setup and teaching doings, performance observation and response, and the institution safety environment. First, it is intended as the questionnaire and organized in 5 segments founded on the WHO Multimodal Hand Hygiene 5 Improvement Strategy components. Second, it comprises of twenty seven indicators imitating the main elements of every strategy module and was verified in 19 countries’ 26 institutions beforehand World Health Organisation issuance. Third, every indicator is allocated a value totalling to a 100 maximum points in every section of the total 5 sections. 500 points is therefore the maximum overall HHSAF score. Founded on a institutions’ score, it is apportioned to each of four progress levels in continuum of hand hygiene enhancement.

Direct observation

Inconspicuous straight observation of practices on hand-hygiene by an expert observer is measured as the gold evaluation compliance standard. Hand Hygiene Australia, the Australian national hand hygiene campaign created an internet established application on monitoring handhygiene compliance (HHCApp) liberally available for application by any other state campaigns or such healthcare institutions. Individual and national healthcare facilities are recommended by World Health Organisation to implement the Technology application and participate in this international data collection project. Inventive electronic methods Encouraging advanced electronic schemes for automatic observation of compliance of hand-hygiene are currently available and significantly enable data gathering. Such permit continuous watching over a long time and such analysis and download of data automatically. Notably, the Hawthorne effect is expressively mitigated and minimal human resources are required (WHO literature review 2016, p.3). As long as World Health Organisation 5 moments for hand hygiene are covered, such innovative technologies offer various returns and might well develop the imminent tactic to monitoring compliance of hand hygiene if accessible assets authorize. An alternative beneficial indicator is application of hand hygiene products, in particular the alcohol-based hand rub. Data is easily calculated and correlated with infection tendencies over a period of time. Nevertheless, they should be used in parallel with hand hygiene compliance data, to be accommodating in persuading HCWs’ behavioural change.

Monthly auditing

In UK, A 30 day audit of compliance to hand hygiene is implemented in all in-patient divisions with reaction given independently to clinicians. Though hand hygiene is the centre of the audit, it provides a suggestion of infection control standards within the section (NHS UK 2016, p.7). This hygiene audit entails; first, that all infection deterrence and control strategies are updated to reveal best exercise, national direction and direct nurses to convey finest practice and decrease patient risk. Second, the avoidance and control of infection links employee network extends to guarantee one linkage worker for every medical team to encourage best exercise by being example and decreasing threats to patients. Third, link employees or nurses implement onsite audits of hand hygiene, training assemblies and aptitude assessments of fellow peers. This progress reduces the periods consumed in lecture theatres for training conferences assisting clinical regions to convey care of great quality.

Hand hygiene and infection control laws and policies

The 2008 Health and Social Care Act; Code of Practice for the National Health Service on the healthcare related infections control and prevention and the associated direction is superior to the 2006 Health Act; practice code for the healthcare connected infections control and prevention to state that all workers should exhibit good hygiene infection regulation and practice. The 2008 Health and Social Care Act provides the NHS institution must maintain and provide an appropriate and clean atmosphere for healthcare and must ensure adequate delivery of appropriate facilities of hand washing and sterile hand rubs. The body is obliged to similarly provide data on healthcare associated infections to boost compliance. The word healthcare associated infections comprises of every infection by such infectious proxy attained as a result of an individual’s NHS treatment or worker of healthcare in the progress of their NHS responsibilities (NHS 2006, P.5). Such hand hygiene is a serious feature in averting the blowout of such infections in healthcare sceneries.

Change of strategy

A multidisciplinary, multimodal strategy is prospective necessary than the behavioural theory. Most outstandingly, an enhancement in practices on infection governance needs First, questioning rudimentary beliefs, Second, unceasing group assessment of stage of behavioural variation, third, interventions with a suitable change process, and lastly, backing group and individual creativity (Kretzer 1998, p.317). For the reason that complication of the change process, sole interventions repeatedly end up unsuccessful. Devotion to endorsed practices of hand hygiene must become a portion of the patient safety culture where unrelated quality fundamentals interrelate to realize a shared goal (Boyce and Pittet, 2016). Policies to progress adherence to practices of hand hygiene must be both multidisciplinary and multimodal.

Need for further research

The resolution of further research is to describe and identify nurse attitudes and beliefs on hand-hygiene and their views of the multilevel aspects that inspire such behaviour. Such allows researchers identify elements of the evidence-practice gap, that is, why compliance to nurse hand hygiene is inconsistent; explicit behaviours that require modification in order to raise nurse compliance of hand-hygiene; in addition the exact goals to remain covered by the theory founded data paraphrase intercession. Such essential initial labour generates an exhaustive appreciation of nurses’ views of the multilevel elements of behaviours essential to progress nurse compliance to hand hygiene. Prevailing data comes mainly from semi designed interviews with nurses and inhabitants. There is need to supplement such data with nonparticipant surveillance of nurses and inhabitants’ practices of hand-hygiene, throughout recurrently led clinic hand-hygiene audit meetings and such emphasis groups with experts of hand-hygiene

In conclusion, the multimodal arrangement of structure and behavioural strategies is essential to investigating, understanding, , and mitigation of prevailing gaps in the compliance of hand-hygiene; removal of hindrances to routine of hand-hygiene; and encourage health care staffs that such compliance to hand-hygiene is significant, required, besides being treasured.

References

Abbreviations

HCAI- HealthCare Associated Infection

HH – Hand Hygiene

HHCApp – Hand Hygiene Compliance Application

HHSAF – Hand Hygiene Self-Assessment Framework

MHHIS – Multimodal Hand Hygiene Improvement Strategy

WHO – World Health Organisation

Journals, Articles

Akyol, A.D., 2007. Hand hygiene among nurses in Turkey: opinions and practices. Journal of clinical nursing, 16(3), pp.431-437.

Berhe, M., Edmond, M.B. and Bearman, G.M., 2005. Practices and an assessment of health care workers’ perceptions of compliance with infection control knowledge of nosocomial infections. American journal of infection control, 33(1), pp.55-57. [online] Available at: http://www.ajicjournal.org/article/S0196-6553(04)00569-3/abstract  [Accessed 29 Oct. 2016].

Boscart, V., Fernie, G., Lee, J. and Jaglal, S. (2012). Using psychological theory to inform methods to optimize the implementation of a hand hygiene intervention. Implementation Science, [online] 7(1), p.p.1. Available at: http://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-7-77 [Accessed 29 Oct. 2016].

Boyce, J.M., Pittet, D. and Solomon, M.D., (2002) Guidelines for Hand Hygiene in Health Care Settings. Review of the Scientific Data Regarding Hand Hygiene. [online] Cdc.gov. Explore Hand Hygiene Compliance Among Nursing in Healthcare Setting Using Behavioral Theory17 Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm [Accessed 28 Oct. 2016].

Bradley, S. (2016). A Systems and Behavioral Approach to Improve Hand Hygiene Practice. [online] Patientsafetyauthority.org. Available at: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2014/Dec;11(4)/Pages/1 63.aspx [Accessed 28 Oct. 2016].

Fuller, C., Michie, S., Savage, J., McAteer, J., Besser, S., Charlett, A., Hayward, A., Cookson, B., Cooper, B., Duckworth, G., Jeanes, A., Roberts, J., Teare, L. and Stone, S. (2012). The Feedback Intervention Trial (FIT) — Improving Hand-Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial. PLoS ONE, [online] 7(10), p.e41617. Available at: http://journals.plos.org/plosone/article? id=10.1371/journal.pone.0041617 [Accessed 28 Oct. 2016].

Hand Hygiene Australia, (2016). Hand Hygiene Australia – What is Hand Hygiene?. [online] Hha.org.au. Available at: http://www.hha.org.au/AboutHandHygiene.aspx [Accessed 28 Oct. 2016].

Karaaslan, A., Kepenekli Kadayifci, E., Atıcı, S., Sili, U., Soysal, A., Çulha, G., Pekru, Y. and Bakır, M. (2014). Compliance of Healthcare Workers with Hand Hygiene Practices in Neonatal and Pediatric Intensive Care Units: Overt Observation. Interdisciplinary Perspectives on Infectious Diseases, [online] 2014, pp.1-5. Available at: https://www.hindawi.com/journals/ipid/2014/306478/ [Accessed 28 Oct. 2016].

Explore Hand Hygiene Compliance Among Nursing in Healthcare Setting Using Behavioral Theory18 Karabay, O., Sencan, I., Sahin, I., Alpteker, H., Ozcan, A. and Oksuz, S., 2005. Compliance and efficacy of hand rubbing during in-hospital practice. Medical principles and practice, 14(5), pp.313-317.

Kretzer, E.K. and Larson, E.L., 1998. Behavioral interventions to improve infection control practices. American journal of infection control, 26(3), pp.245-253. Mele, A.R., 2001. Self-deception unmasked. Princeton: Princeton University Press.

NHS Foundation Trust, (2016). HAND HYGIENE POLICY. 1st ed. [ebook] Sheffield: Sheffield Teaching Hospitals, pp.4-20. Available at: https://www.sheffield.ac.uk/polopoly_fs/1.29490!/file/HandHygienePolicy.pdf [Accessed 28 Oct. 2016].

NHS UK, (2016). Quality Account Report.. 2nd ed. [ebook] National Health Service, pp.6-78. Available at: http://www.nhs.uk/aboutNHSChoices/professionals/healthandcareprofessionals/qualityaccounts/Documents/2013/KCHT-Quality%20Account-12-13.pdf [Accessed 28 Oct. 2016].

Ott, M. and French, R., 2009. Hand hygiene compliance among health care staff and student nurses in a mental health setting. Issues in mental health nursing, 30(11), pp.702-704.

Ott, M. and French, R., 2009. Hand hygiene compliance among health care staff and student nurses in a mental health setting. Issues in mental health nursing, 30(11), pp.702-704.

Pyne, E., Physician Attitudes toward Hand Hygiene in the Acute Care Setting; 2012. Explore Hand Hygiene Compliance Among Nursing in Healthcare Setting Using Behavioral Theory19

Shukla, U., Chavali, S. and Menon, V. (2014). Hand hygiene compliance among healthcare workers in an accredited tertiary care hospital. Indian Journal of Critical Care Medicine, [online] 18(10), p.689. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4195200/ [Accessed 28 Oct. 2016].

Sickbert-Bennett, E., DiBiase, L., Willis, T., Wolak, E., Weber, D. and Rutala, W. (2016). Reduction of Healthcare-Associated Infections by Exceeding High Compliance with Hand Hygiene Practices. Emerg. Infect. Dis., [online] 22(9), pp.1628-1630. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4994356/ [Accessed 28 Oct. 2016].

Tibballs, J., 1996. Teaching hospital medical staff to handwash. The medical journal of Australia, 164(7), pp.395-398. WHO Healthcare, (2016). The critical role of infection prevention and control. 1st ed. [ebook] World Health Organisation, pp.3-26. Available at: http://apps.who.int/iris/bitstream/10665/246235/1/WHO-HIS-SDS-2016.10-eng.pdf? ua=1 [Accessed 28 Oct. 2016].

WHO HHSF, (2016). Hand Hygiene Self-Assessment Framework. 1st ed. [ebook] World Health Organisation, pp.1-9. Available at: http://www.who.int/gpsc/country_work/hhsa_framework_October_2010.pdf?ua=1 [Accessed 28 Oct. 2016].

WHO literature review, (2016). Systematic literature review of automated/electronic systems for hand hygiene monitoring Preliminary results. 1st ed. [ebook] World Health Organisation, Explore Hand Hygiene Compliance Among Nursing in Healthcare Setting Using Behavioral Theory20 pp.1-3. Available at: http://www.who.int/gpsc/5may/automated-hand-hygienemonitoring.pdf?ua=1 [Accessed 28 Oct. 2016].

WHO Report on the Burden of HCAIs, (2011). Report on the Burden of Endemic Health CareAssociated Infection Worldwide. 1st ed. [ebook] World Health Organisation. Available at: http://apps.who.int/iris/bitstream/10665/80135/1/9789241501507_eng.pdf?ua=1&ua=1 [Accessed 28 Oct. 2016].

WHO Report, (2016). Summary Report: Hand Hygiene Self-Assessment Framework Survey 2015/2016. 1st ed. [ebook] 1-19: World Health Organisation. Available at: http://www.who.int/gpsc/5may/hand-hygiene-report.pdf [Accessed 28 Oct. 2016].

WHO, (2016). A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. 1st ed. [ebook] World Health Organisation, pp.4-48. Available at: http://apps.who.int/iris/bitstream/10665/70030/1/WHO_IER_PSP_2009.02_eng.pdf [Accessed 28 Oct. 2016].

WHO, (2016). WHO | Hand hygiene monitoring and feedback. [online] Who.int. Available at: http://www.who.int/gpsc/5may/monitoring_feedback/en/ [Accessed 28 Oct. 2016].

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