Design and methods
We collected the demographic data during the first on-site visit in each RCH unit included in this study. The demographic data included the following: number of residents, number of healthcare workers, availability of alcohol-based hand rubs (ABHR), and availability of washing facilities. The observations of ICP include hand hygiene, use of gloves, use of personal protective equipment (PPE), respiratory hygiene, handling of sharp equipment, decontamination of equipment, waste management, and environmental cleaning [13,14,19]
We conducted an observational study to observe ICP among healthcare workers in private and government-subsidized RCHs. In this study, the researcher (as a non-participant observer) was a qualified registered nurse who had been trained and had accumulated experience in patient care. This ensured that the researcher was familiar with ICP. The researcher recorded observations at any time in different shifts (morning or afternoon shifts) every day (from Monday to Sunday) in different units of both the private and subsidized RCHs. This allowed for the collection of comprehensive data on staff behavioral changes in different shifts during the weekdays and weekends . For such consecutive observations done for 2–3 weeks in each RCH, the Hawthorne effect was reduced by desensitizing the healthcare workers to the frequent presence of the observer. Such a method has been suggested elsewhere  and is considered more reliable for continuous sampling. The observed healthcare workers were chosen randomly to minimize the selection bias. Once the observed staff was chosen, the researcher did not interrupt the care procedure. As the opportunities occurred, the performances were recorded by using an electronic tool, called the “eRub.” According to the guideline, hand hygiene involved ABHR and the use of soap and water for at least 20 seconds under the condition of the “five moments for hand hygiene” .
The studied setting included both subsidized and private RCHs with similar sizes in order to reduce the confounding factors in different RCHs. A list of RCHs was retrieved from the Social Welfare Department to identify the private and subsidized care attention homes for the elderly. Such homes for the elderly are the most common types of RCHs in Hong Kong, making up 80% of the total. Thus, this can be considered as a representative sample. Medium-sized RCHs with three floors and around 200 residents were invited by contacting the superintendent/managers by phone.
The subsidized RCHs had 180–220 beds, 99% of which were occupied throughout the year. Single rooms were unavailable and four to eight residents of the same gender shared a partitioned room per bed unit. The toilet and bathroom were shared within a room. The RCHs employed over 90 staff members (staff-to-resident ratio is about 1:2) to provide diverse care and services. Staff in RCHs included professional staff (i.e., registered nurses, enrolled nurses, physiotherapist and occupational therapist), health workers, personal care workers, and workmen.
In comparison, in private RCHs, specific levels or categories of care do not exist. These homes accommodate about 150–300 residents who require diverse levels of care, ranging from minimal personal care to medium nursing care. Only about 70%–80% of beds are occupied throughout the year. Some single rooms are provided, but rooms shared by 4–12 residents of the same gender are common. However, toilets and bathrooms are shared with all residents in the same floor. The common areas include the combined sitting and dining room, the recreation room, and the consultation and treatment rooms. In terms of staffing, these homes employ about 50–70 staff members (approximate ratio of staff to residents is 1:5) to provide a diverse range of care and services, including basic care, nursing care, social and support services, food preparation, and housekeeping. The core staff includes professional staff (i.e., registered nurses and enrolled nurses), personal care workers and workmen. Social workers, physiotherapists and occupational therapists work on part-time basis or are shared within and among the organizations. Although the duties and work patterns are similar to those of subsidized RCHs, the ratios of different staff grades vary. For example, such homes have scarce nursing staff but more personal care workers. According to the regional authority body and statute , annual infection control training for all healthcare workers working in RCH is mandatory.
For observations, in every RCH, we separated each floor into several units depending on the geographic location (i.e., common area and bedroom area), because of the difference in intensity and types of care provided. A common area (e.g., dining area) is the place shared by all the residents, and most of the group activities are held there. Bedrooms are for resting and receiving direct personal care, such as wound dressing and tube feeding. Finally, there are 6 units in the subsidized RCHs (3 units of common areas, 3 units of residential bedrooms) and 5 units in private RCHs (2 units common of areas and 3 units of residential bedrooms). The floor with only bed-bound residents (18 residents) in private RCHs was not accessible for making observations, because the relatives of the residents refused to allow the residents to participate in this study.
Samples and sampling methods
According to the World Health Organization (WHO) guideline , the minimum sample size for hand hygiene audit is 200 opportunities per unit per observation period, and each observation session should be 20 minutes (up to 10 minutes longer or shorter) with no more than three observed participants to be observed simultaneously. Our researcher strictly followed these guidelines. The observation targets were healthcare workers, including nurses (registered nurses and enrolled nurses), allied healthcare professionals (AHCPs, i.e., physiotherapists and occupational therapists), health workers (HWs) and personal care worker (PCWs), who were the ones directly giving care for the elderly.
We recorded the ICP episodes by using an electronic tool called “eRub,” which is the checklist of ICP by international guideline . The observation items in the eRub include hand hygiene performance, use of gloves, respiratory hygiene, disinfecting used surfaces/equipment, handling of linen, handling of clinical waste, handling of sharp equipment, use of PPEs, and likelihood of hand colonization. This electronic tool is convenient for observers as it allows them to gather data immediately and saves time for data entry. Furthermore, using the mobile phone for data collection is better than the pen-and-paper method, because it can reduce the errors committed in gathering large amounts of data and can be more unobtrusive in performing observation.
The interrater agreement test between a research nurse (one observer for all data collection) and infection control expert was established by using WHO Training Film in the Implementation Toolkit. The score of >0.8 reliability was achieved before the commencement of data collection. This test is important in ensuring the consistency of an observer’s observational rating and increasing the validity of the data obtained .
A three-point scale was used to calculate the hand hygiene performance score (0=missing to perform, 1=performed with hand hygiene <20 seconds, and 2=well performed with hand hygiene >20 seconds), use of gloves (0=did not perform, 1=improperly performed, and 2=properly performed), and respiratory hygiene (0=did not perform, 1=improperly performed, and 2=properly performed).
Descriptive and inferential statistics were used to analyze the data by using SPSS (Window version 25.0). The ICP episodes were summarized by descriptive statistics. The significant differences in performance scores between healthcare workers working in private and subsidized RCHs and between those in common areas and residential room areas were determined by independent t-tests. The different performance scores of the healthcare workers were compared by using One-way ANOVA test and post-hoc analyses. Two variables (hand hygiene performance and use of gloves) were calculated by Pearson product moment correlations.