The Handwashing Gap: what was taught in school vs. what is practised in healthcare facilities

It has been a year since Nita* started working in a hospital, and she clearly remembers her first day at work.

Mornings are the busiest time of day for all health care workers, and Nita’s first morning at work was no exception. It was filled with patients and their family members coming in to seek health services. Several female patients were in labor, and some had already entered the delivery room. Midwives were moving around quickly to be able to attend several patients at the same time. Because no one was able to assist a delivery with her, the head of midwife requested Nita’s help in the delivery room.

Nita was feeling happy, but nervous at the same time as it was the first delivery she was to assist in this hospital. She started off by washing her hands, going through the steps that she had learned from school. Even though it took her a while to go through all the steps, she felt proud of herself in achieving this milestone. Meanwhile, she noticed that the other midwife did not do the same handwashing steps as she did, skipping some steps before wearing gloves. She assumed this was because everything was so hectic in the delivery room. Nita said nothing, and proceeded to assist the delivery.

Once the delivery was finished, she asked the other midwife why she skipped some steps in handwashing with soap before wearing gloves. The other midwife told Nita to follow the process that she did because it saved time and it was the norm in this ward. Being a newcomer, Nita chose to keep silent while trying to adapt herself into this new setting.

When she assisted later deliveries and post-natal cares, she observed the same handwashing behaviour among other health care workers in her hospital. Now this norm was becoming Nita’s norm and she felt that she must follow the more senior midwives. Now, she can no longer remember the handwashing steps she learned at school and feels that her current hand hygiene practices are not done according to the proper national guidelines.

Practicing proper hand hygiene is one of the most effective ways healthcare workers can prevent the spread of infections. Meanwhile it promotes respect of patient’s dignity and ensures occupational safety for the healthcare workers themselves. An early study in 2017 found that handwashing facilities and materials were available in approximately 92% of health care facilities].

Nita’s story reinforces the need to shift the focus from investing in infrastructure to changing health care workers’ behavior. A recent WaterAid report ‘Transforming health systems: the vital role of water, sanitation and hygiene’ elaborated that ‘although [infrastructure] is an important element, ensuring that good-quality service delivery and behavior change lasts requires strong health systems’.

Hand hygiene is integrated into formal education through different curriculums in Cambodia’s medical schools, and graduates like Nita are expected to use their knowledge to inform their practices. However, this is not always the case.

Nita’s story was shared during a field visit to a health care facility in one of WaterAid Cambodia’s target provinces, Kampong Chhnang. As explicated in this story, the practice of handwashing with soap can be shaped when medical graduates enter the work environment. In other words, knowledge does not necessarily influence hand hygiene among health care worker. Therefore, it is essential to investigate the main driving forces in hand hygiene by taking into consideration social dynamics within health care facilities.

*name has been altered to hide the person’s identity.

WaterAid's work in healthcare centres in Cambodia is supported by the Australian Government through the Australian NGO Cooperation Program (ANCP).

This story was written by Ms. Ponnary Pors, WASH and Health Officer, WaterAid Cambodia.