A number of causes have been identified for low rates of handwashing, some of which are a product of the work environment. Studies indicate that workers with the highest workload are the least likely to wash their hands; lack of time is one of the most commonly cited reasons for failure to wash hands. In a survey of health care workers, 75 percent stated that rewards or punishments would not increase handwashing, but 80 percent said that easy access to sinks and handwashing facilities would. Studies also have indicated that rubbing hands with a small amount of fast-acting antiseptic is more effective and takes less time than traditional soap-and-water handwashing. A recent study comparing alcohol hand rubs with soap-and-water handwashing found that hygienic hand rubs could reduce handwashing time by more than 75 percent Lautenbach (2001). A national stakeholders meeting convened in July 2003 by the U.S. Centers for Disease Control and Prevention (CDC) and the American Hospital Association (AHA) reaffirmed that alcohol-based hand rubs are more effective in reducing bacteria on workers’ hands, save workers’ time, and are associated with improved adherence to guidelines on handwashing. This stakeholder meeting was convened to identify ways that hospitals can fully use alcohol-based hand rubs and not jeopardize fire safety (CDC, 2003). Some also have suggested that the application of behavior theory and human factors approaches to infection control practices might help achieve sustained increases in handwashing rates (Lautenbach, 2001).

Reduced Patient Safety Due to Inefficient Nurse Work Processes

A number of studies provide evidence that nurses spend a significant portion of their time in activities that are inefficient and decrease the amount of time they have available to monitor patient status, provide therapeutic patient care, and educate patients. In a survey of 50 percent of RNs living in Pennsylvania, 34.3 percent of hospital nurses reported performing housekeeping duties, 42.5 percent delivering and retrieving food trays, and 45.7 percent transporting patients. Of these same nurses, 27.9 percent and 12.7 percent, respectively, reported leaving undone patient/family education and patient/family preparation for discharge (Aiken et al., 2001). When delivery of medications, medical equipment or supplies, blood products, or laboratory specimens is needed for the patient and transport staff are not available, this activity often is carried out by the nurse. Such practices occur frequently (Prescott et al., 1991; Upenieks, 1998). In separate studies comparing the efficiency of two different nurse call systems, 50 to 80 percent of calls were found not to require a response from a licensed nurse (Miller et al., 1997, 2001).

More recently, in a work sampling study involving 239 hours of observation of 26 hospital nurses at nine hospitals with a reputation among



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