Knowledge about hand hygiene in the Generation Z: A questionnaire-based survey among dental students, trainee nurses and medical technical assistants in training

•A survey regarding hand hygiene among 470 young health care professionals in training.•There was a lack of knowledge especially regarding the indications for hand hygiene.•“No time” was a frequent perception for non-compliance to hand hygiene.•Women performed better than male participants.•Nurses and medical technical assistants performed better than dental students. Alcohol-based hand disinfection is the key measure to prevent healthcare-associated infections and nosocomial transmission of pathogens. We conducted a survey among dental students, trainee nurses and medical technical assistants in training from the Generation Z to determine their knowledge regarding hand hygiene and to optimize education. Overall knowledge was worthy of improvement. Females performed better than males. Specifically tailored efforts seem necessary to increase hand hygiene competence in the Generation Z. Alcohol-based hand disinfection is the key measure to prevent healthcare-associated infections and nosocomial transmission of pathogens. We conducted a survey among dental students, trainee nurses and medical technical assistants in training from the Generation Z to determine their knowledge regarding hand hygiene and to optimize education. Overall knowledge was worthy of improvement. Females performed better than males. Specifically tailored efforts seem necessary to increase hand hygiene competence in the Generation Z. Alcohol-based hand disinfection represents the key infection control measure to prevent healthcare-associated infections and nosocomial transmission of pathogens.1Huang GK Stewardson AJ Grayson ML Back to basics: hand hygiene and isolation.Curr Opin Infect Dis. 2014; 27: 379-389Crossref PubMed Scopus (28) Google Scholar It is crucial to continuously improve hand hygiene compliance, especially when teaching young prospective healthcare professionals. These are nowadays mainly members of the so-called Generation Z2Wells T Fishman EK Horton KM Rowe SP Meet generation Z: top 10 trends of 2018.J Am Coll Radiol. 2018; 15: 1791-1793Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar (ie, those born between 1995 and 2012). We conducted a survey to determine the knowledge regarding hand hygiene in this group and to assess the potential for optimizing education. This voluntary survey included a paper-based questionnaire with 11 questions. It was distributed to dental students (DENT), trainee nurses (NURS), and medical technical assistants in training (TECH) at different levels of education. In total, 470 prospective healthcare professionals (334 females and 136 males) participated in the survey (reply rate >95%). All participants were affiliated with the Hannover Medical School, which is a 1,500-bed university hospital in Northern Germany. The questions were inspired by the Hand Hygiene Knowledge Questionnaire for Health-Care Workers from the World Health Organization (WHO; revised version of August 2009)3World Health Organization (WHO). Hand hygiene knowledge questionnaire for health-care workers. Available at: https://www.who.int/gpsc/5may/tools/evaluation_feedback/en/. Accessed October 17, 2019.Google Scholar and by a previous survey among medical students.4Graf K Chaberny IF Vonberg R-P Beliefs about hand hygiene: a survey in medical students in their first clinical year.Am J Infect Control. 2011; 39: 885-888Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar The questions 1 to 9 were multiple choice questions with one single correct answer choice or a correct combination of answer choices, respectively. In the latter question type all correct answer options had to be marked to answer correctly. The questions 1 to 9 were used to check the participants’ knowledge (knowledge score). Questions 10 and 11 asked the participants for an estimate of hand hygiene compliance (in percentage) in clinical practice and for perceptions for noncompliance. The questions are shown in Table 1 and Figure 1. The participants were also asked to provide age and gender. We compared the knowledge score (questions 1 to 9) in different subgroups using either the Mann-Whitney U test or the Kruskal-Wallis test. A P<.05 was considered significant. Questions 10 and 11 were analyzed descriptively. Statistical analysis was performed using SPSS 25 (IBM SPSS statistics, Somers, NY). We obtained ethical approval for this study by our institution's ethics committee (number 8701_BO_K_2019).Table 1Characteristics of the participants and survey results (questions 1 to 10)CharacteristicsDENTNURSTECHAllYear of education13451231No. of all participants9754595274593837470No. of female participants6631384157452828334No. of male participants312321111714109136Mean age in years (range)*13 participants of the entire cohort forgot to report their age.21 (17-33)24 (20-33)24 (20-35)24 (21-32)22 (16-42)22 (18-34)23 (19-35)20 (18-39)22 (16-42)1. What is the main transmission mode for pathogens in a hospital? (one answer only)•Contaminated hands of medical staff•Air•Contaminated surfaces•Commonly used non-invasive medical products (eg, stethoscope)f34 (51.5)23 (74.2)30 (78.9)23 (56.1)47 (82.5)37 (82.2)18 (64.3)23 (82.1)235 (70.4)m11 (35.5)15 (65.2)15 (71.4)8 (72.7)13 (76.5)10 (71.4)6 (60.0)5 (55.6)83 (61.0)2. What is the main source for pathogens causing nosocomial infections? (one answer only)•Water system•Air•The patient's own microbiota•Contaminated surfaces•Staff's microbiomef16 (24.2)8 (25.8)10 (26.3)7 (17.1)26 (45.6)15 (33.3)8 (28.6)15 (53.6)105 (31.4)m7 (22.6)5 (21.7)3 (14.3)4 (36.4)7 (41.2)1 (7.1)3 (30.0)4 (44.4)34 (25.0)3. When should a hygienic hand disinfection be performed?•Before contact to a patient•Before preparing an intravenous medication•After taking off disposable gloves•After contact with the patient's bed•After contact with the patient's salivaf27 (40.9)22 (71.0)16 (42.1)8 (19.5)31 (54.4)24 (53.3)15 (53.6)18 (64.3)161 (48.2)m8 (25.8)14 (60.9)14 (66.7)3 (27.3)6 (35.3)10 (71.4)7 (70.0)6 (66.768 (50.0)4. Which of the following hygienic hand disinfections are important to prevent transmission of a pathogen to a patient from a healthcare worker?•Before a healthcare worker touches a patient•After a healthcare worker had contact with a body fluid•After a healthcare worker had contact with the patient surrounding•Before a healthcare worker performs an aseptic proceduref29 (43.9)0 (0.0)7 (18.4)11 (26.8)11 (19.3)14 (31.1)0 (0.0)13 (46.4)85 (25.4)m8 (25.8)0 (0.0)8 (38.1)1 (9.1)5 (29.4)5 (35.7)0 (0.0)2 (22.2)29 (21.3)5. Which of the following hygienic hand disinfections are important to prevent pathogen transmission from a patient to a healthcare worker?•After a healthcare worker touched a patient•After a healthcare worker had contact with a body fluid•Before a healthcare worker performs an aseptic procedure•After a healthcare worker had contact with the patient surroundingf30 (45.5)0 (0.0)20 (52.6)18 (43.9)30 (52.6)30 (66.7)0 (0.0)14 (50.0)142 (42.5)m9 (29.0)0 (0.0)12 (57.1)1 (9.1)11 (64.7)9 (64.3)0 (0.0)2 (22.2)44 (32.4)6. Which answers are correct with respect to hand washing/hygienic hand disinfection?•For mechanical cleaning of dirty hands, hygienic hand disinfection is superior to hand washing•Hygienic hand disinfection dries the skin out more than hand washing with soap•Hygienic hand disinfection reduces bacterial burden more than hand washing with soap•Hygienic hand disinfection should always be done after hand washing with soap•When hands are visibly contaminated hand washing with soap should be performed prior to hygienic hand disinfectionf5 (7.6)0 (0.0)6 (15.8)7 (17.1)10 (17.5)7 (15.6)0 (0.0)1 (3.6)36 (10.8)m1 (3.2)0 (0.0)5 (23.8)1 (9.1)2 (11.8)1 (7.1)0 (0.0)0 (0.0)10 (7.4)7. What is the recommended duration of hygienic hand disinfection (in Germany)? (one answer only)•30 seconds•3 seconds•1 minute•10 secondsf44 (66.7)22 (71.0)24 (63.2)30 (73.2)55 (96.5)39 (86.7)24 (85.7)25 (89.3)263 (78.7)m23 (74.2)17 (73.9)16 (76.2)4 (36.4)16 (94.1)11 (78.6)9 (90.0)9 (100)105 (77.2)8. When is hand washing with either soap (A) or a hygienic hand disinfection (B), both (C) or nothing at all (D) necessary?•Before touching a patient: B•Before administering local anesthesia: B•After cleaning used medical products: B•After discharging medical gloves: B•After having disinfected a dentist's chair: B•After visible contact with blood: Cf0 (0.0)2 (6.5)2 (5.3)1 (2.4)7 (12.3)4 (8.9)4 (14.3)0 (0.0)20 (6.0)m0 (0.0)1 (4.3)0 (0.0)0 (0.0)0 (0.0)1 (7.1)0 (0.0)0 (0.0)2 (1.5)9. What is unfavorable when performing hygienic hand disinfection?•Wearing rings on the hands•Presence of a chronic skin disease•Wearing artificial fingernails•Regular use of skin care lotionf44 (66.7)0 (0.0)25 (65.8)25 (61.0)35 (61.4)20 (44.4)0 (0.0)24 (85.7)173 (51.8)m19 (61.3)0 (0.0)16 (76.2)7 (63.6)14 (82.4)8 (57.1)0 (0.0)9 (100)73 (53.7)10. How high do you estimate overall compliance to hygienic hand disinfection in healthcare settings in percent? (Results as mean percentage)†8 participants of the entire cohort forgot to provide an estimate for the compliance rate.f486547594947534452m516040534951565852Questions 1 to 9: The total number of participants with a correct answer is displayed in the columns; the percentages – referring to each females and males - are given in the brackets. The answer options rated as correct are indicated in bold.DENT, dental students; NURS, trainee nurses; TECH, medical technical assistants in training, f, female, m, male. 13 participants of the entire cohort forgot to report their age.† 8 participants of the entire cohort forgot to provide an estimate for the compliance rate. Open table in a new tab Questions 1 to 9: The total number of participants with a correct answer is displayed in the columns; the percentages – referring to each females and males - are given in the brackets. The answer options rated as correct are indicated in bold. DENT, dental students; NURS, trainee nurses; TECH, medical technical assistants in training, f, female, m, male. The characteristics of the cohort and the results for the questions 1 to 10 are displayed in Table 1. Figure 1 shows the results for question 11. “No time” and “forgotten” were the most frequent perceptions for noncompliance to hand hygiene. Females had higher knowledge scores compared to males (females, mean rank 244.77 vs males, mean rank 212.74; Mann-Whitney U test, Z = -2.358, P = .018). Looking at first year participants, there were significant differences between medical technical assistants in training, trainee nurses and dental students (TECH, mean rank 131.77 vs NURS, mean rank 122.97 vs DENT, mean rank 80.01; Kruskal-Wallis test, H = 31.707, df = 2, P<.0001). This difference was caused by the performance of the dental students, as there was no significant difference between the both other groups (TECH, mean rank 59.08 vs NURS, mean rank 54.46; Mann-Whitney U test, Z = -7.30, P = .466). In the trainee nurses group there were significant differences between the years of education (year 1, mean rank 102.75 vs year 2, mean rank 94.26 vs year 3, mean rank 40.55; Kruskal-Wallis test, H = 43.584, df = 2, P<.0001). The performance was best in year 1 of education and worst in year 3 (Spearman correlation: -0.436, P<.0001). Age did not have a significant influence. The survey showed interesting aspects regarding knowledge and perceptions of the Generation Z that should be taken into account when addressing hand hygiene. Interestingly, the most frequent assumptions for noncompliance to hand hygiene in our cohort were “no time” and “forgotten” (question 11, see Fig 1), whereas in the survey by Graf et al. from 2011 (which addressed millennials back then)4Graf K Chaberny IF Vonberg R-P Beliefs about hand hygiene: a survey in medical students in their first clinical year.Am J Infect Control. 2011; 39: 885-888Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar the most common answer from medical students was “too lazy.” Less than 10% of each the female and male participants chose that type of answer in our cohort. This might be an expression of a professional and value-led attitude toward hygiene in the Generation Z, in which “laziness” is not acceptable as a reason for noncompliance. “No time”, however, was also an often reported perception of nurses for noncompliance in another study5Sadule-Rios N Aguilera G Nurses’ perceptions of reasons for persistent low rates in hand hygiene compliance.Intensive Crit Care Nurs. 2017; 42: 17-21Crossref PubMed Scopus (33) Google Scholar and in our study the trainee nurses mentioned this point most frequently too. Our cohort assumed that hand hygiene compliance is approximately 50% in clinical practice. This assumption is somewhat chastening for infection control specialists. However, it fits to findings reported in literature.6Mutters NT Hägele U Hagenfeld D Hellwig E Frank U Compliance with infection control practices in an university hospital dental clinic.GMS Hyg Infect Control. 2014; 9 (Doc18)PubMed Google Scholar,7Labrague LJ McEnroe-Petitte DM van de Mortel T Nasirudeen AMA A systematic review on hand hygiene knowledge and compliance in student nurses.Int Nurs Rev. 2018; 65: 336-348Crossref PubMed Scopus (36) Google Scholar We found that females had a better overall knowledge regarding hand hygiene. This phenomenon was also recently reported for hand hygiene adherence in a hospital setting.8Laskar AM R D Bhat P et al.A multimodal intervention to improve hand hygiene compliance in a tertiary care center.Am J Infect Control. 2018; 46: 775-780Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Moreover, it was found in the general public that females had a better knowledge with regard to hand hygiene.9Suen LKP So ZYY Yeung SKW Lo KYK Lam SC Epidemiological investigation on hand hygiene knowledge and behaviour: a cross-sectional study on gender disparity.BMC Public Health. 2019; 19: 401Crossref PubMed Scopus (71) Google Scholar Altogether, this underlines that it may be necessary to specifically address male prospective healthcare professionals of the Generation Z and to further investigate the reasons for this gender discrepancy and how to overcome it. The results of the questions 1 to 9 revealed further interesting aspects. It is noteworthy that first year dental students had less knowledge than first year trainee nurses and medical technical assistants in training. This may be due to the fact that teaching hand hygiene is not present in the current curricular courses in the first year of education in dentistry, which focuses on practical skills. Moreover, we documented that especially the questions 4, 6, and 8 were answered incorrectly. These questions address the WHO's 5 moments for hand hygiene and hand washing with soap. Thus, it seems appropriate to focus on these issues and maybe to implement innovative lectures10Hampton D Welsh D Wiggins AT Learning preferences and engagement level of generation Z nursing students.Nurse Educ. 2020; 45: 160-164Crossref PubMed Scopus (22) Google Scholar and practical training to foster learning. The role of hand washing compared to hygienic hand disinfection was not clear to many participants. Therefore, teaching should clarify in more detail in which situations either hand washing or hygienic hand disinfection or both are appropriate. In addition, we recognized that the questions 6 and 8 were quite complex which might have also contributed to the low performance. The performance of the trainee nurses was worst in the last year (third year) of education. The reason for this finding is somehow unclear and should be reviewed in future investigations. Our analysis has limitations. First, the survey was conducted at a single institution in Germany. This means that our findings might not necessarily apply to other settings. Moreover, we focused on 3 subgroups (dental students, trainee nurses and medical technical assistants in training). Therefore, a comparison to other prospective healthcare professionals (eg, medical students) might be difficult to some extent. Our survey design was inspired by others such as the WHO questionnaire. Since we adapted the questions, comparability with these surveys may be limited. However, the modifications were necessary to meet our local standards as exactly as possible which guaranteed a good acceptance resulting in a high number of participants. In conclusion, we showed that among prospective healthcare professionals of the Generation Z knowledge with respect to hand hygiene is worthy of improvement. Teaching should particularly address the indications for hand hygiene and their practical implementation. In this context, specifically tailored teaching efforts regarding content and techniques on how to meet the needs of Generation Z students may be beneficial. In addition, we think that it is useful to regularly analyze hand hygiene knowledge during education to optimize and customize curricular teaching. From an infection control point of view it makes sense to address and foster hand hygiene in prospective healthcare professionals of the Generation Z as they will work in patient care for many years and they will act as role models for further generations. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. The authors would like to thank the participants of the survey. Moreover, we would like to thank Professor Franz-Christoph Bange and Professor Werner Geurtsen for careful and critical reading of the manuscript.