Pensar Enfermagem / v.29 n.01 / March 2025
DOI: 10.71861/pensarenf.v29i1.353 /e00353
Review Article
)
How to cite this article: Siviero LG, Braz PR, Prado RT, Carbogim FC, Nascimento TC, Rodrigues FC,
Alvim ALS. Clinical governance through audit in promoting quality in clinical practice: scoping review. Pensar
Enf [Internet]. 2025 Mar; 29(1): e00353. Available from: https://doi.org/10.71861/pensarenf.v29i1.353
Adherence and incentive strategies for hand hygiene
in endoscopy: integrative review
Abstract
Introduction
Hand hygiene in endoscopy is still a topic addressed in a limited way in the literature, with
predominantly unicentric studies and small sample sizes, lacking a synthesis of evidence.
This limitation prevents a comprehensive evaluation of adherence and incentive strategies,
which justifies conducting this review.
Objective
To identify, through literature, the adherence and incentive strategies for hand hygiene in
the endoscopy sector.
Methods
This is an integrative review conducted on databases including PubMed, Scopus, Web of
Science, LILACS, BDENF, WPRO, CAPES Periodicals Portal, and the SciELO library.
For the selection of articles, the inclusion criteria established were: full texts available for
free and/or for purchase, with no time restrictions, and published in English, Portuguese,
or Spanish. To maintain methodological rigor during the search strategy, a double-blind
selection of articles was independently conducted.
Results
A total of 204 publications were retrieved, with the final sample consisting of six studies.
Of these, only two addressed adherences to hand hygiene in the endoscopy sector.
Regarding incentive strategies, all publications highlighted educational interventions, the
implementation of the Plan, Do, Check and Act (PDCA) cycle, performing hand hygiene
throughout the endoscopic procedure to avoid self-contamination, patient engagement, as
well as support from leaders and the inclusion of the topic during the training process of
healthcare professionals.
Conclusion
Literature identified adherence and incentive strategies for hand hygiene in endoscopy.
However, the lack of studies on the subject is emphasized, with most research conducted
during the Covid-19 pandemic.
Keywords
Hand hygiene; Endoscopy; Health Personnel; Patient Care; Review.
Luan Gonçalves Siviero1
orcid.org/0009-0005-2506-3010
Patrícia Rodrigues Braz2
orcid.org/0000-0003-2102-635X
Roberta Teixeira Prado3
orcid.org/0000-0001-8738-2248
Fábio da Costa Carbogim4
orcid.org/0000-0003-2065-5998
Thiago César Nascimento5
orcid.org/0000-0002-2304-7472
Flávia Cristina Rodrigues6
orcid.org/0000-0003-2063-8506
André Luiz Silva Alvim7
orcid.org/0000-0001-6119-6762
1 Bachelor. Universidade Federal de Juiz de Fora,
Brasil.
2 PhD. Centro Universitário Estácio Unidade Centro
Sul - Juiz de Fora, Brasil.
3 PhD. Universidade Federal de Juiz de Fora, Brasil.
4 PhD. Universidade Federal de Juiz de Fora, Brasil.
5 PhD. Universidade Federal de Juiz de Fora, Brasil.
6 Bachelor. Universidade Federal de Juiz de Fora,
Brasil.
7 PhD. Universidade Federal de Juiz de Fora, Brasil.
Corresponding author:
André Alvim
E-mail: andrealvim1@ufjf.br
Received: 07 Oct 2024
Accepted: 01 Mar 2025
Editor: Florinda Galinha de Sá
Alvim, A.
Review Article
Introduction
Hand Hygiene (HH) consists of a set of simple techniques
that aim to reduce the microbial load on the hands. It can
be performed by simple hygiene, with water and liquid soap
and/or aqueous solution of alcoholic base (ASAB),
antiseptic hygiene with friction and surgical antisepsis. Due
to its relevance in the health area, this practice was included
in the Patient Safety protocols and recommended by the
World Health Organization (WHO) in five essential
moments: before touching the patient, before clean/aseptic
procedures, after exposure to body fluids, after touching the
patient and after touching surfaces near the patient.1
HH represented a great advance for the health area, since its
precursor, Ignaz Philipp Semmelweis, observed that, when
performed frequently, this measure considerably decreased
the cases of infection.1-2 Considered a low-cost preventive
measure, rapid and efficient in the control of healthcare-
related infections (HCRI), its application in all levels of
health care stands out.2
Among the sectors covered by the different complexities of
health care in which HH should be applied, there stands out
the Endoscopy.3 It is the place intended for the performance
of endoscopic procedures for diagnosis and interventions,
using rigid or flexible equipment and whose way of access
to the body includes cavities such as oral, nasal, external ear
canal, anus, vagina and urethra. It includes the presence of
equipment, materials and products related to health that are
used in invasive procedures that penetrate the skin, mucous
membranes, sterile spaces or cavities, subepitelial tissues and
vascular system.3
A review study on the subject reveals that adherence to HH
in endoscopy by health professionals is still below expected.
Although professionals report a 95% adherence, this rate
reaches just over 10%. In this case, the associated factors
highlighted in the literature include the complexity of
routine, lack of awareness and the perception that this
preventive measure is not a priority. Strategies to encourage
hand hygiene in this sector, through continuing education,
awareness campaigns, regular monitoring and feedback, are
key tools in clinical practice. However, the topic is addressed
in a limited way in the literature, with studies predominantly
unicentric with reduced samples, lacking a synthesis of
evidence. This limitation prevents a comprehensive
evaluation of the adherence and incentive strategies, which
justifies this review.
The objective of this study is to identify, through literature,
adherence and strategies for encouraging hand hygiene in
endoscopy.
Methods
This is an integrative literature review, guided by the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA). Although PRISMA is intended
for systematic review and meta-analysis studies, its
contribution to this research to increase the rigor of
scientific writing becomes important.
There were six methodological steps in this review:
establishment of the starting question; search for samples
in the literature; categorization of the found material;
evaluation of the studies included during the review;
interpretation of the results found; synthesis of the acquired
information.6
As a strategy to formulate the starting question, the PICo
strategy was used, establishing the research problem to
substantiate the best evidence. This method was stratified
in: (P) study population = health professionals; (I)
phenomenon of interest = adherence and strategies to
encourage hand hygiene; (Co) context = studies performed
in endoscopy. The use of this tool to establish the research
problem sought the foundation in the best evidence. This
said, the following guiding question emerged: how does the
literature describe adherence and strategies to encourage
hand hygiene among professionals in endoscopy?
The strategy to search for samples in the literature was
carried out between January and March 2024 in the
databases of the National Library of Medicine (PubMed),
Latin American and Caribbean Health Sciences Literature
(LILACS), Nursing Databases (BDENF), Index Medicus do
Pacífico Ocidental (WPRO), Portal de Periódicos da Coordenação
de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and the
digital library Scientific Electronic Library Online
(SciELO). For the scientific information research strategy,
MeSH descriptors and free terms were used with the help
of the Boolean operators AND and OR. The material
found was then categorized (Table 1).
Pensar Enfermagem / v.29 n.01 / March 2025
DOI: 10.71861/pensarenf.v29i1.353 /e00353
Review Article
Table 1: Search strategy in the literature, Juiz de Fora, Minas Gerais, Brazil, 2024.
Descriptors and free terms
[Hand disinfection] OR [Hand hygiene] AND [Health personnel] AND [Endoscopie] OR
[Endoscopy] OR [Endoscopies]
[Hand disinfection] OR [Hand hygiene] OR [Infection control] AND [Health personnel] AND
[Endoscopy]
[Hand disinfection] OR [Hand hygiene] OR [Healthcare workers] AND [Endoscopy]
[Higienização das mãos] OR [Desinfecção das mãos] OR [Controle de infecção] OR
[Prevenção de infecção] AND [Profissionais de saúde] AND [Endoscopia]
[Higienização das mãos] OR [Desinfecção das mãos] OR [Controle de infecção] OR
[Prevenção de infecção] AND [Profissionais de saúde] AND [Endoscopia]
[Hand disinfection] OR [Hand hygiene] OR [Healthcare workers] AND [Endoscopy]
[Desinfecção das mãos] OR [Higienização das mãos] AND [Profissionais de Saúde] AND
[Endoscopia]
[Desinfecção das mãos] OR [Higienização das mãos] AND [Endoscopia]
The inclusion criteria established to select the articles were:
full texts available free of charge and/or subject to
payment, without time restriction, and published in
English, Portuguese or Spanish. Publications from journals
that did not undergo peer review, editorials, books, letters
to the editor, reflection studies and/or that did not directly
address the starting question were excluded, and duplicate
articles. Initially, the title and abstract were read and, in
cases of inclusion, a full reading of the article was carried
out, as well as all the bibliographical references included in
this study.
To maintain methodological rigor during the search
strategy, two reviewers selected the articles independently.
Subsequently, the information was reviewed together and
thus the process was completed. In the interpretation of the
results obtained and in the synthesis of the information
acquired, a chart was elaborated to systematize the
knowledge, with the definition of the following variables:
author, article title, journal, country of study, methodology,
level of evidence and main highlights.
The data were analyzed through simple descriptive statistics
and categorized in a visual map for the synthesis of results.
Results
Figure 1 shows the identification of studies through the
databases and records, according to PRISMA. The eight
databases selected for this research returned 204 studies.
After the evaluation of publications and the removal of
duplicate articles and/or that did not address the theme, the
final sample was composed by six articles.
Alvim, A.
Review Article
Figure 1: PRISMA Flowchart of the integrative review.5
Table 2 presents the synthesis of the articles selected for
review. In terms of temporal delimitation, most articles
were published in 2021 (50%), mainly during the period of
the Covid-19 pandemic. Six scientific journals were
identified, with the United States (33.3%) and Brazil
(33.3%) being the main countries of origin of the research.
As for the methodology used by the researchers, different
designs were identified, with emphasis on descriptive
studies. Only two studies addressed adherence to hand
hygiene in the endoscopy sector,13-14 while all presented
strategies to encourage this preventive measure.9-12
Table 2: Summary of articles selected for review, 2024.
Author
(year)
Title
Journal
Country
of study
Methodology
Main highlights
Karels et
al.
(2022)9
Impact of Infection
Control Education
on Gastrointestinal
Endoscopy
Procedural Staff
Gastroent.
Nursing
United
States
Quasi-
experimental
study.
Educational interventions were
provided to endoscopy healthcare
professionals on the five moments
recommended by WHO, which
improved the results of the
questionnaire implemented for
evaluation.
Kong et
al.
(2021)10
The application of
plan, do, check, act
(PDCA) quality
Int J Clin
Pract
China
Pre and post-
intervention
study
The implementation of the PDCA
cycle was a strategy that improved the
medical team's knowledge about
Studies removed before
screening:
Duplicate articles removed
(n=14)
Studies excluded
(n = 129)
Studies not retrieved (file
unavailable for reading and/or
incomplete)
(n = 5)
Studies excluded:
Did not describe teaching-
learning strategies related to
patient safety
(n = 50)
Studies included
PUBMED (n = 5)
Web of Science (n = 1)
Identification of studies via databases and records
Identification
Selection
Inclusion
Studies identified:
PUBMED (n = 8)
SCOPUS (n = 33)
Web of Science (n = 53)
LILACS (n = 3)
BDENF (n = 2)
WPRO (n = 1)
CAPES (n = 103)
SciELO (n= 1)
Total = 204
Studies sought for assessment
(n = 61)
Studies assessed for eligibility
(n = 56)
Studies screened
(n = 190)
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management in
reducing nosocomial
infections in
endoscopy rooms: It
does work
HCRI and hand hygiene, when
compared to the control group.
Murcio-
Pérez et
al.
(2021)11
Adherence to
recommendations for
endoscopy practice
during Covid-19
pandemic in Latin
America: how are we
doing it?
BMJ Open
Gastroenterol
Latin
American
Countries
Prospective
study
Encouraging hand hygiene among
patients, aiming at empowerment,
was one of the strategies used to
prevent HCRI, recommended by the
medical team during the Covid-19
pandemic in Latin America.
Pombo
et al.
(2021)12
Endoscopy infection
control strategy
during the Covid-19
pandemic: experience
from a tertiary cancer
center in Brazil
Clinics (São
Paulo)
Brazil
Retrospective
study
Hand hygiene was encouraged,
especially: before entering the
procedure room, after completion of
the endoscopy and outside the room,
aiming to avoid self-contamination.
Pedersen
et al.
(2017)13
Barriers, perceptions,
and adherence: Hand
hygiene in the
operating room and
endoscopy suite
Am J Infect
Control
United
States
Descriptive,
cross-sectional
study
The adherence of health professionals
was 11%. One reported incentive
strategy refers to the support of
leaders, including direction and
inclusion of the topic throughout the
training process, during graduation.
Santos et
al.
(2013)14
Improving hand
hygiene adherence in
an endoscopy unit
Endoscopy
Brazil
Descriptive,
cross-sectional
study
Adherence improved from 21.4% to
73.5% after the implementation of an
educational intervention, which was
highlighted as a teaching strategy for
hand hygiene.
Note: WHO = World Health Organization; PDCA = Plan, Do, Check, Action
Figure 2 shows the strategies to encourage hand hygiene,
namely: educational interventions,1 implementation of the
PDCA cycle,1 HH performed in five moments to avoid
self-contamination12, patient empowerment11, the support
of leaders and the inclusion of the theme during the training
process of health professionals13.
Alvim, A.
Review Article
Figure 2: Strategies to encourage hand hygiene in the endoscopy sector, 2024.
Discussion
This study showed that adherence to HH in the endoscopy
sector needs improvement. Although the literature lacks
studies with high levels of evidence, it is worth highlighting
that incentive strategies focused on health education,
implementation of continuous improvement cycles, such as
the PDCA, the implementation of this preventive measure
at the times recommended by the WHO, the support of the
management and the inclusion of the theme in the training
process of professionals can contribute to improve
adherence, both among the team and among patients.
The results of this study show the importance of
strengthening adherence to the five hand hygiene moments
recommended by the WHO, essential to prevent infections
and reduce cross-transmission in sectors such as
endoscopy. Although the literature highlights the relevance
of this practice, data point to variable rates of adherence
and often inadequate techniques, indicating a gap between
international guidelines and practical reality.1
The importance of hand hygiene in endoscopy is widely
recognized, considering its potential for contamination.
Health professionals working in this sector should carry out
this preventive measure appropriately, following the
correct technique proposed by the WHO. This is
underlined by data from a study conducted in two
endoscopy centers in South Korea. In this research,
surfaces such as computer keyboards and mouse were
analyzed, finding the presence of non-pathogenic
microorganisms, such as Staphylococcus spp. These
microorganisms have the potential to trigger cross-
contamination between people, patients and/or
environments, highlighting hands as a mode of direct
contact transmission.1 In this place, HH is recommended
at three times to avoid self-contamination: before entering
the procedure room, after completion of endoscopy and
outside the room.12 However, although this study has
highlighted three moments, it is essential to follow the five
moments for hand hygiene recommended by the WHO.
Adherence to these five moments not only decreases
infection rates, but also promotes a culture of safety and
quality in care, reinforcing the commitment to evidence-
based practices that protect patients' health and the
integrity of professionals, minimizing cross-transmission
risks and promoting safer working environments.1
This research identified a varied adherence to hand hygiene
in two publications, with rates ranging from 11% to
73.5%.13,14 This picture is not limited to endoscopy, as other
hospital sectors also face low adherence. An observational
study conducted in a coronary unit of a university hospital
highlighted a rate of 38.2%, with nursing technicians and
doctors presenting the lowest results.1 Another study
revealed concerning data for patient safety, indicating that
80% of the health professionals observed performed the
technique incorrectly.1 In this context, it is necessary to
implement measures to encourage HH as an integral part
of the awareness strategies in the team’s routine, especially
multimodal interventions, and establish accountability
metrics.17,18
There is a great challenge in maintaining high HH rates
among health professionals. Nevertheless, studies included
in this integrative review, conducted by this population and
that addressed health education, observed an increase in
adherence after interventions, both with the team and with
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Review Article
patients.9,11,14 A study on the application of educational
activities demonstrated that the use of strategies with a
more playful approach can facilitate the understanding and
retention of knowledge, contents and relevant factors on a
given theme, as is the case of the triggers of HCRI and the
ways to avoid them. This incentive strategy brings benefits
to both professionals and patients.19
Another strategy to encourage HH refers to the use of the
PDCA cycle as a tool with wide applicability.10 This method
consists of a continuous improvement cyclic process,
organized in four stages: P (Plan), moment when the
problem is defined and action methods are planned; D
(Do), when the implementation of the planned methods
occurs through training/teaching to employees; C (Check),
aiming to verify the results of actions; and A (Action), to
act in correcting unwanted effects or points that can be
improved. This method is effective and applicable in
several areas of knowledge, including endoscopy,
contributing to the expansion of hand hygiene coverage.20
An aspect to be considered is the inclusion and discussion
of hand hygiene as an incentive strategy to prevent HCRI
throughout the training process of health professionals,
especially during graduation. A survey using the Delphi
technique with health professionals specialized in the area
of prevention and control of infections discussed the
teaching of this topic in graduate courses in the health area.
There was consensus that teaching this practice at this stage
has a great impact on the training of future professionals
who understand the importance of measures to prevent
and control infectious diseases in the workplace.21
In this context, the need for practice fields to be equipped
with appropriate materials, appropriate physical structure,
personnel sizing and efficient programs for the
improvement of health professionals is discussed. This
allows the continuity of what is learned in the classroom
and what is practiced in real scenarios, representing one of
the main challenges in consolidating knowledge. There are
often many discrepancies between what is taught during
graduation and practice. The HH theme should be
addressed in a transversal way in higher education
institutions, encouraging initiatives that stimulate critical-
reflective and creative thinking, as well as methodologies
that sensitize students about the subject.22
An important contribution of this study is that the analysis
of publications revealed important insights for clinical
practice. There was a significant gap in the approach to
hand hygiene adherence, with only two studies exploring
this issue. However, incentive strategies were identified to
promote its practice. These findings not only emphasize the
need for a broader approach to ensure patient safety, but
also provide opportunities for the implementation of
effective interventions in the endoscopy sector.
Conclusion
This study identified the adherence and strategies to
encourage hand hygiene in endoscopy. However, the
results highlight the need to increase adherence in this
sector, since the rates may be low in the absence of
interventions on the team. It is worth mentioning the
strategies of incentive to this preventive measure, especially
educational interventions, the use of the PDCA tool, the
technique performed by health professionals throughout
the endoscopy procedure, the support of the leaders and
the inclusion of the theme in the training process of these
professionals.
The literature on the subject was scarce, as evidenced by
the final sample included in the review. Half of the studies
included in this research were conducted during the Covid-
19 pandemic. New studies should be encouraged in
endoscopy, especially multicenter, so that it is possible to
better understand the reality of the sector in relation to the
subject.
Study limitations
The limitations of the study are strongly associated with the
methodological choices adopted in the integrative review,
which may have affected the validity and generalization of
the results. First, the selection of studies revealed a possible
publication bias, since many of the included articles were
carried out during the Covid-19 pandemic. This exceptional
context may have changed hand hygiene practices, as more
rigorous protocols were in place at that time. Moreover, the
scarcity of studies conducted after the pandemic limits the
ability to assess adherence and strategies for encouraging
hand hygiene in more recent scenarios when working
conditions and practices may have changed.
Another relevant methodological limitation is related to the
inclusion criterion of studies, since, as it is an integrative
review, it was necessary to consider the heterogeneity of the
methodologies used in the included studies. This may have
compromised the comparability and depth of analysis, as
different methodological approaches and research contexts
influence the consistency of results. In addition, the scarcity
of studies with higher level of evidence, such as randomized
clinical trials, made it difficult to make robust findings and
apply broader conclusions. This limitation is particularly
important, since the lack of rigorous studies compromises
the strength of the evidence and the possibility of
generalizing the results to a wider population.
Authorship
Siviero LG: Conception and design of the study; Data
collection; Data analysis and interpretation; Writing the
manuscript; Critical revision of the manuscript; Approval of
the final version of the manuscript and taking responsibility
for it;
Braz PR: Critical revision of the manuscript; Approval of
the final version of the manuscript and taking responsibility
for it;
Prado RT: Critical revision of the manuscript; Approval of
the final version of the manuscript and taking responsibility
for it;
Carbogim FC: Critical revision of the manuscript; Approval
of the final version of the manuscript and taking
responsibility for it;
Alvim, A.
Review Article
Nascimento TC: Critical revision of the manuscript;
Approval of the final version of the manuscript and taking
responsibility for it;
Rodrigues FC: Critical revision of the manuscript; Approval
of the final version of the manuscript and taking
responsibility for it;
Alvim ALS: Conception and design of the study; Data
analysis and interpretation; Writing the manuscript;
Approval of the final version of the manuscript and taking
responsibility for it.
Conflicts of interest and Funding
No conflicts of interest have been declared by the authors.
Sources of support / Financing
The study was not funded.
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