Enf.ª Nadine Candeias Gonçalinho

Nurse Internship in the Master's Degree Course in Nursing in the area of Specialization in Medical-Surgical Nursing in People in Critical Situations

Enf.ª Patrícia Santos

Specialist Nurse in the Infection Control Unit

Hand hygiene as a basic precaution for infection prevention and control.
Reflection article

HPA Magazine 23 // 2025

IF YOU WERE THE PATIENT TODAY, WOULD YOU QUESTION YOUR CLINICAL PRACTICE REGARDING HAND HYGIENE?
WOULD IT BE THE SAME ONE YOU WOULD LIKE TO BE ADOPTED DURING YOUR TREATMENT?

Hand hygiene is considered one of the most important measures for reducing the transmission of infectious agents between patients during care provision, according to the Direção Geral da Saúde (DGS). Around 30% of Healthcare Associated Infections (HAIs) can be prevented with correct hand hygiene implementation.
To comply with this, professionals must keep their nails clean and short, without nail polish, extensions, or other artifacts. They must remove ornaments, and cuts and abrasions must be protected. The 5 moments of hand hygiene must be respected, and an alcohol-based antiseptic solution (SABA) must be used, available with the patient. If hands are visibly dirty or contaminated, or in contact with patients with gastrointestinal infections, they should be washed with soap and water.

ADHERENCE TO HAND HYGIENE IN THE HPA
According to data from the UL-PPCIRA Annual Report of the HPA Saúde Group for the year 2023, the global adherence rate to hand hygiene was 81%. This value represents an increase compared to the previous year, where the adhesion rate was 78%. Evaluating the data regarding the first moment of hand hygiene "before contact with the patient," there was also an improvement in the adherence rate. In 2022, the rate was 69%, and in 2023, it increased to 74%. Despite the improvements seen in both rates, they fall short of the DGS target, which defines a rate equal to or greater than 90%.
The results show that we are below what would be expected. And why? It is not uncommon to find that healthcare professionals continue to fail to comply with the implemented guidelines despite being aware of them. We all know the implications of these actions, yet we continue to violate them! The price to be paid is very high, and has implications for ourselves, our families, and the community at large. So, what leads healthcare professionals to not adhere to good practices when it comes to hand hygiene?

HAND HYGIENE AND OBSTACLES TO ITS ADHESION
According to the Joint Commission International, the success of initiatives aimed at improving adherence to hand hygiene practices depends on several factors, including effective strategies, elements related to health professionals, organizational characteristics, patients and their families, as well as the external environment. Effective strategies include training and education, implementing alert systems, internal audits, and providing performance feedback. Factors related to health professionals include their knowledge, attitudes, and behaviours. Regarding organizational characteristics, the availability of resources, leadership capacity, and the involvement of hierarchies in a safety culture stand out.
A study showed that more than three -quarters of the justifications presented by health professionals for non-adherence to hand hygiene were related to three behavioural domains: Memory, Attention, and Decision Making (44%), Knowledge (26%), and Environmental Context/Resources (9%). Other behavioural domains, such as beliefs about consequences, nature of behaviour, skills, emotions, and social norms, explained only 8% of the cases, while 15% of the justifications could not be associated with any domain.
Another study, when analysing the factors that influence adherence to hand hygiene based on the factors identified by the WHO, organizes them into three categories: material, social and behavioural, and institutional. Material factors refer to the availability of products and infrastructure, such as SABA, sinks, and dispensers close to patients. Social and behavioural factors are divided into intrapersonal, such as educational level, knowledge, personality, culture, and religion, and interpersonal, which include social identity, concern for other people's opinions, and role in society. Institutional factors include feedback, workload, recognition, and promotion of participation in hygiene programs, and are linked to the culture of safety, training, and co-responsibility for infection control

Cognitive-behavioural factors, which include lack of habit, forgetfulness, boredom, and inertia in repeating the same procedures several times a day, are also cited as reasons for non-adherence to hand hygiene; scepticism about the importance and value of practicing procedures associated with hand hygiene and their positive results; and failures in self-efficacy.
The data presented demonstrate the complexity involved in adhering to hand hygiene practices, highlighting that this is influenced by individual, organizational, and cultural factors. However, when considering the role of nurses, it is essential to recognize that these professionals must assume a position of leadership and responsibility in promoting a culture of safety. Hand hygiene is not just a simple technique but an essential act that reflects the commitment of health professionals to Beauchamp & Childres' ethical principle of non-maleficence or "first, do no harm."
To ensure quality care and a culture of patient safety, it is known that the training and qualification of health professionals are crucial in the area of infection prevention and control. Developing training plans based on identified needs and a culture of patient safety leads to greater patient involvement and promotes good practices.
The Centers for Disease Control and Prevention in North America consider a positive relationship between the qualification of health professionals and the reduction in the prevalence of Healthcare-Associated Infections (HAIs).
Regarding the training of health professionals in infection prevention and control, evidence suggests that while increasing knowledge is essential, training alone does not maintain high levels of adherence. Therefore, it is recommended to implement strategies such as continuous monitoring of practices, with direct observation being an important measure.

CONCLUSION
Neglect or poor adherence to hand hygiene can seriously compromise the care provided and invalidate treatment efforts.
Non-adherence to hand hygiene can lead to hospital infections, prolonged hospital stays, and avoidable suffering.
Therefore, it is crucial to emphasize that the safety and quality of care provided involve training and educating the team and raising awareness among all health professionals about the importance of hand hygiene.