Hand hygiene as a caring practice : a refl ection on professional responsibility

Hand hygiene represents a fundamental nursing care practice and is traditionally considered the most important and effective measure in the prevention and control of healthcare-related infections. However, studies indicate that adherence to the procedure is unsatisfactory throughout the world, and show low adherence rates. In a context in which patient safety stands out as a priority, this text submits refl ections about professional responsibility when not adhering to hand hygiene practices, and ethical aspects related to this conduct. Descriptors: Hand hygiene; Patient safety; Nursing care; Knowledge, Health Knowledge, Attitudes, Practice; Cross Infections. RESUMO A higienização das mãos (HM) representa uma prática fundamental do cuidado de enfermagem e é tradicionalmente considerada como a medida mais importante e efi caz na prevenção e controle de infecções relacionadas à assistência à saúde. Entretanto, estudos apontam que a adesão ao procedimento é insatisfatória em todo o mundo e evidenciam baixas taxas de adesão. Num contexto no qual a segurança do paciente destaca-se como prioridade, o texto traz refl exões acerca da responsabilidade profi ssional ao não aderir às práticas de HM e de aspectos éticos relacionados a essa conduta. Descritores: Higiene das Mãos; Segurança do Paciente; Cuidados de Enfermagem; Conhecimentos, Atitudes e Prática em Saúde; Infecção Hospitalar. RESUMEN La higienización de las manos (HM) representa una práctica fundamental del cuidado de enfermería, y es tradicionalmente considerada como la medida más importante y efi caz para la prevención y control de infecciones relacionadas a la atención de salud. No obstante, estudios expresan que la adhesión al procedimiento no es satisfactoria en todo el mundo y evidencian bajas tasas de adhesión. En un contexto en el cual la seguridad del paciente se destaca como prioridad, el texto refl exiona acerca de la responsabilidad profesional al no adherir a las prácticas de HM y sobre aspectos éticos relacionados a dicha conducta. Descriptores: Higiene de las Manos; Seguridad del Paciente; Atención de Enfermería; Conocimientos, Actitudes y Práctica en Salud; Infección Hospitalaria. Hand hygiene as a caring practice: a refl ection on professional responsibility Higienização das mãos como prática do cuidar: refl exão acerca da responsabilidade profi ssional Higienización de las manos como práctica del cuidar: refl exión acerca de la responsabilidad profesional REFLEXTION Aline Santa Cruz Belela-Anacleto E-mail: aline.belela@unifesp.br CORRESPONDING AUTHOR

Since Florence Nightingale, fundamental health care needs represent elements that support nursing practice.Activities such as hand hygiene (HH), oral hygiene, positioning in bed, and skin care for intravenous catheters are elementary in the healing process, health maintenance, promotion of comfort, and prevention of complications.However, although the Hippocratic premise "do no harm" is a requirement for all professionals who provide care, evidence reveals the existence of a wide and risky gap between the care that the patient should receive and that which is actually performed: a scenario characterized by successive injuries caused by such lack of care (1)(2) .
Despite imprecise estimates of the extent of the problem, current knowledge indicates that millions of people around the world suffer disabling injuries or die as a result of errors during health care delivery, indicating that patient safety is a global public health issue.
Health care-related infections, estimated to occur in one out of every 20 hospital patients, represent the most frequent type of adverse event as a result of medical care.Considered to be an unintended occurrence, they are responsible for high rates of morbidity and mortality, increased length of hospital stay, increased resistance of microorganisms to antimicrobials, and generate long-term incapacities, high expenses for patients and families, preventable deaths, as well as a great impact on the system in terms of financial costs.Some multifaceted causes are related to structure limitations, to the multiple intricate processes within the complex health system, and to the human behavior, conditioned, among others, by the educational process (1,3) .
Hand hygiene is traditionally considered the most important and effective measure for prevention and control of such events, and is characterized as a routine, standardized, low-cost action with indications based on solid scientific evidence.However, in the age of evidence-based practice, the adherence to this procedure is still described as insufficient worldwide (1,4) .
In a recent systematic review of 16 clinical trials, conducted between 2009 and 2014, the mean adherence to HH was 34.1%, with a mean rate of 56.9% after interventions (1) .In this sense, there is a consensus on the need to implement a robust and integrated set of actions to promote adherence to the HH procedure.Research indicates that individual measures are not able to modify and maintain the HH behavior of health professionals for a long time; it also emphasizes that the sustainability of this change is a great challenge (1,(3)(4)(5) .
The World Health Organization (WHO) proposed the multimodal strategy known as "Clean Care is Safer Care" to promote adherence to HH practices around the world, beginning in 2005, as part of the first Global Patient Safety Challenge.The strategy includes system changes, ensuring easily accessible resources for the procedure, education and training of the multidisciplinary team, emphasizing the concepts, importance of individual behavior and the safety culture, observation and performance feedback, using reminders in the workplace, and establishment of a security climate based on institutional commitment.In the last decade, several efforts have been made to implement this strategy, which has become a priority in several programs to promote quality and patient safety worldwide (1,5) .
In the field of patient safety, the assumptions of the systemic approach to error are accepted and applied for their understanding and prevention.Error-prone systems are the source of most of the failures which occur, and which are committed by competent, motivated and hard-working professionals to provide safe, quality care.In such circumstances, one of the major challenges in this area is the establishment of a safety culture, characterized by a non-punitive environment, free of individual guilt, prioritizing the detailed investigation of the facts in order to enable the development of preventive strategies.As a premise, the fallibility of the human being is a condition assumed as immutable, which requires changes in its working conditions to prevent such events (1,6) .
However, although health care systems are an obvious source of factors that lead to error, such as uncertain and dynamic environments, intensive work by newly trained professionals, work overload, actions with immediate and multiple consequences, situations highly influenced by organizational culture, among others, it is argued that ethical issues involving patient rights and institutional and professional duties are implicated, and they are discussed in this context (1)(2)(3)(4)(5) .The culture of non-punishment advocated in the systemic approach to human error cannot divert attention from the critical function of professionals in the complex health system, requiring reflection on personal and organizational duties, and the balance between them (5) .
By definition, ethics is related to the duties of public order and are related to a set of principles that aim to establish obligations on the part of the people contemplated, here referred to as the standards of professional activities (6) .Conceptually, the field of ethics studies the relationship between the individual and the context in which he is situated (7) .
In the healthcare field, the ethical principles of autonomy, nonmaleficence, beneficence and justice must guide all actions, as they qualify the individual's caring action (8) .Considering that the referential applied to the action determines the value imposed on the action, it is believed that it is important to stimulate reflection about what can be considered morally justifiable in the behavior of HH presented by professionals who have the care for life as a primary objective (6)(7)(8) .
Among several concepts, morality is understood as, a system of norms, principles and values, according to which mutual relationships between individuals, or between them and the community, are regulated in a non-coercive way, provided with a historical and social character, and freely accepted and by intimate conviction (7) .
Morality can be understood as the consultation of reason, thus acting morally is based on the best justification for doing so, considering the interests of each individual to be affected by taking certain action (8) .
Evidence demonstrates, for more than 150 years, that the hands of health professionals are the main vector of transmission of pathogenic microorganisms, and that sanitizing them Hand hygiene as a caring practice: a reflection on professional responsibility Belela-Anacleto ASC, Peterlini MAS, Pedreira MLG.
contributes to a reduction in the incidence of infections (1,(3)(4)(5) .Nonetheless, acceptable levels of adherence to recommended HH practices are difficult to achieve and sustain.The principles of moral and professional responsibility of individuals are challenged by not adhering to the recommended procedures, in circumstances in which the basic requirements to promote the execution of the HH procedure are available (5) ."Responsibility, as a moral requirement, implies assuming, recognizing and responding to the consequences of one's own acts", establishing a balanced relationship between rights and duties (8) .
The reduction of healthcare-related adverse events requires not only the redesign of an imperfect system, but also the recognition of individual responsibility by actions that can weaken or disorganize it.If higher adherence rates must be achieved and sustained beyond the promotion campaigns, it is mandatory that the HH becomes a habit (1,5) .Considering that the moral subject is obliged to act by certain rules, the healthcare professional is expected to pay attention to the pertinence of his decisions and actions in the exercise of his duties, to provide the best possible practice (9)(10) .
Regarding the individual, once the structure and processes necessary for an activity are established, the professional's non-adherence to it should be considered in order to clarify which behaviors are acceptable in that context.Limits must be established between expected human fragilities and levels of performance below the expected professional standards and, from these, what interventions should be proposed.Currently, the lack of incentive to comply with rules, and the absence of consequences for not doing so, creates a vicious cycle considered to be an additional system issue (1,5) .
Errors may occur due to the exploratory aspect inherent in the learning process related to clinical work, in an environment characterized by the interrelation of people and technologies with specific and complementary functions, and where a great diversity of tasks are performed on vulnerable individuals in a critical and dynamic context (5) .However, in such circumstances, some distinction must be made between error, non-intentional situations, and what is considered a violation.The low adherence to HH is a violation of the prescribed norms (2,5) .
According to Runciman et al. (10) , while the error originates in the human condition and its prevention is related to the system's ability to avoid it, violations proceed from human behavior and culture.The differences involve an element of choice and result in actions that deviate from established norms, incurring risks, even without any intention of harm.
In this context, violations are classified as: unintentional violations (related to lack of knowledge or experience), exceptional violations (occurrence of unusual circumstances requiring exceptional responses), situational violations (when the environment hinders adherence), routine violations (characterized by the regular occurrence), and optimizing violations (there is intention to improve a certain situation) (11) .The specific example of HH is classified as a routine violation, defined as that which occurs in the execution of daily activities (5) .Hand hygiene at the right time with a correct technique represents a professional obligation, since the violation of this basic pattern of care cannot continue to be justified as a system failure (5) .
Patient safety, as a concept, implicitly presents a fundamentally ethical nature.In the perception of moral value, it involves arguments related to the protection and promotion of human dignity, characteristics that must be imperative in the individual action (5,(10)(11)(12) .
In Brazil, the dignity of the human person is a constitutional principle.The respect for human rights, including cultural rights, the right to life, choice and dignity are inherent to the profession of nursing.The fundamental principles of the Code of Ethics for Nurses state that nurses respect life, dignity and human rights, in all its dimensions, and exercise their activities with competence for the health promotion of the human being in his integrity, in accordance with the principles of ethics and bioethics.For Gastmans (12) , the ethical essence of nursing care can be defined as the provision of care in response to the vulnerability of the human being, aiming to maintain, protect and promote his dignity to the maximum extent possible.
Without entering into the merits of the complex concept of human dignity, experts claim that it is determined from the prevailing cultural context of its application: in this case, the health care institution.Primarily, the respect for dignity is established when the interest of the other prevails.Close interactions of the professional with the patient, family and staff require decision-making related to daily care that, in turn, require ethical principles to be interpreted and applied in the process of performing care.In this sense, regardless of didactic definitions, it is a consensus in the literature on the subject that it is urgent to rescue the above mentioned principles and commitment to the other in providing bedside care (12) .
The need for such effort to overcome the adversities described represents a serious issue, specifically with regard to nursing, despite its evolution as a science and practice.Hand hygiene is a fundamental action of patient care, and should be performed as a priority, in a rigorous and routine manner.Imminent intervention is necessary, and it is essential to resume the values attributed to the essential procedures for the practice of health care.Thus, the behavior of HH should constitute, in addition to a technical action, a moral component of the praxis of the nursing professional.
We believe that greater emphasis must be given to HH practices in the political, care and research contexts, in order to achieve cleaner, safer, more effective and higher quality care.