To the best of our knowledge, this is the first study conducted using a unit-based observation approach, which separated the RCHs into different units according to the nature and intensity of care provision. Although there was no significant difference found, such information provided justification to inform future research. Furthermore, this study reported the changes of hand hygiene compliance over a period of 2–3 weeks. Surprisingly, there were no significant changes observed, thereby contradicting previous studies [23]. However, it was plausible that the hand hygiene performance was too low to explain the change. Floor effect was considered in this case.
Many researchers stated that hand hygiene is the most effective elements in preventing infections. A systemic review of the impact of hand hygiene on risk infections in nursing homes revealed that the infection rate decreased when at least one hand hygiene-related intervention (e.g., availability of ABHR) was applied in the study [24]. However, the overall hand hygiene performance was still poor (15%) in the current study even though the sufficient provision of ABHR. This result is similar with of Smith et al. [25] and Ho et al. [26], who reported that the hand hygiene performance rate is 14.7% in two long-term care facilities and ranged from 19.5–27% in subsidized RCHs. Moreover, the availability of ABHR in common areas was better than in the bedroom areas among subsidized and private RCHs. Yet, there was no difference found in the hand hygiene performance between common areas and bedroom areas. This indicated that healthcare workers had no intention to perform hand hygiene even with the presence of ABHR. This contradicts past studies, which reported an increase in hand hygiene compliance with increased availability of ABHR [27][28]. In fact, some studies showed that increase hand hygiene compliance not only increased ABHR but also staff education on the use of such material [25]. PCWs seldom used ABHR compared with other healthcare workers in the current study. Indeed, it was predicted that professionals would have higher hand hygiene compliance than PCWs and HWs due to differences in educational background. Studies on hand hygiene behavior always focused on professional staff in hospital settings, which may not reflect the same situation in the RCH setting in the current study as many healthcare workers completed lower educational levels in RCHs (most staff were PCWs and HWs with secondary school education). Therefore, further assessment of hand hygiene behaviors among PCWs and HWs is necessary in the RCH setting.
In the present study, hand hygiene performance was the best after body fluid exposure risk (46% performed), after the aseptic procedure (25% performed), and after patient contact (25% performed) compared with before patient contact (2%) and after contact with the patients’ surroundings (3%). This result is consistent with previous research, which indicated that there was a significantly higher hand hygiene performance after body fluid exposure, aseptic procedure, and after patient contact compared to before patient contact and after patient surrounding contact [29]. Furthermore, another study showed that the assistant healthcare workers had the worst hand hygiene compliance in each moment compared with nurses and doctors in Turkey [30]. The current study revealed a similar result in which PCWs (similar job duties to assistant healthcare workers) had the worst performance in each moment compared with the professional staff. It is likely that healthcare workers think that the residents’ surroundings colonize with less microorganisms and lower risk of infection [29]. Moreover, in this study, the best performance in the use of gloves was the moment before coming into contact with the patients (38%) and before performing the aseptic technique (68%). It seemed that healthcare workers tend to protect themselves rather than protect others [31]. Therefore, evidence from studies should be shared to convince healthcare workers to practice hand hygiene effectively at each moment.
Meanwhile, wearing the gloves diminished the transmission of organisms by healthcare workers' hand and protected them, whereas the improper use of glove increased the risk of organism transmission [32]. The use of gloves is not a substitute for hand hygiene. In fact, many studies have shown that hand hygiene is worse in case of using gloves. The current study also found that hand hygiene performance decreased with the increased use of gloves. PCWs had the most frequent contact with residents. Yet, they had the worst performance in hand hygiene and use of gloves among the healthcare workers observed in the study. For example, they did not wash their hands after removing the gloves (missing = 98%) and did not change gloves between care procedures among residents (missing = 66.4%). Furthermore, they tended to perform hand hygiene only after completing specific successive tasks for all residents.
Respiratory tract infection (1.3%) is the most common type of infection in RCHs [7]. Respiratory protection is an effective preventive measure to prevent droplet transmission. In this study, most healthcare workers can correctly wear the surgical mask in case respiratory protection was required, yet 30% of healthcare workers failed to wear a surgical mask while performing patient care procedures. There was no observational study on wearing surgical mask in RCHs. The result is the same as that reported in a past study, which showed that most healthcare workers wore a surgical mask correctly in the hospital setting [33].
Overall, the performance in hand hygiene and respiratory protection scores showed no significant difference between common areas and bedroom areas in private and subsidized RCHs. However, the use of gloves had higher frequency in the bedroom areas than in common areas in the moments before performing an aseptic technique (i.e., wound dressing) and before coming into contact with bodily fluids (i.e. changing diaper). Respiratory protection, the use of gloves and hand hygiene had just slightly better performance scores in subsidized than private RCHs. There was not enough significant difference observed in this study, although the manpower practice was much satisfactory in subsidized RCHs than in private ones. Some authors mentioned that ICP was performed better in subsidized RCHs with abundant resources [34]. However, the sample is not adequate to conduct a comparison with the current study.
Studies on ICP in Hong Kong RCHs by observational design without applying interventions have been limited thus far. Wong et al. reported the first survey on the trends of ICP from 2005–2014, revealing that the overall trend of ICP was improved and that ICP in subsidized RCHs is better than in private RCHs due to the related factors (i.e., educational level of staff, resident-to-staff manpower ratio, and compliance with minimum statutory standards in private RCHs) [35]. However, Wong and colleagues only observed two healthcare workers (the infection control officer and one care worker) in each visit per year. Therefore, their results might not reflect the ICP among the majority of healthcare workers. In the current study, although comparisons between subsidized and private RCHs was limited as the sampling size was not adequate, the results can still reflect the preliminary natural performance of ICP among healthcare workers, because continuous observations for 2–3 weeks were made, and the observations were carried out randomly during healthcare workers' routine caring procedure in random.
The most observed ICP elements in this study were hand hygiene, use of gloves, and respiratory protection. However, other elements were not shown by this research, such as disinfecting used surfaces/equipment, handling of linen, handling of clinical waste, handling of sharp equipment, use of PPEs, and the likelihood of hand colonization. These elements were omitted from the observations because these were not routinely performed and can only be observed by chance. In the future, we can obtain data from such practices by using a questionnaire if the procedure will be seldom observed. The generalizability of the study can also be improved by recruiting more participants in the sample of RCHs in future studies.
Meanwhile, healthcare workers had adequate levels of skills and knowledge on ICP [35]. However, ICP among healthcare workers was still poor in this study. This implies that the adoption of ICP is always difficult to implement even if the staff are equipped with adequate knowledge. Compliance with ICP depends on a comprehensive theory behind [36]. PCWs are the main caregivers for residents in RCHs setting. Their workloads are much heavier than those of other types of healthcare workers in RCHs. Thus, future studies can give more focus on their ICP behaviors in this setting.
There are some limitations in the study. Some ICP episodes cannot be easily observed if the procedures were not part of the daily routine. Thus, the study failed to show the comprehensive ICP in RCHs. Second, the private RCHs refused to allow the researcher to observe the bed-bound elderly (18 residents) housed on the same floor. Hence, the results may not totally reflect the actual ICP compliance in private RCHs.