The quality of nursing care regarding personal hygiene of patients admitted to a selected hospital in the Kavango region

The aim of the study was to determine the quality of nursing care regarding personal hygiene of patients ad­ mitted to a hospital in the Kavango region of Namibia. The study was prompted by repeated media reports over the radio. Commentators and listeners expressed con­ cern over the seeming lack of adequate hygienic meas­ ures, specifically with regard to patient care. To objectively quantify and describe the extent ot this problem, a single objective was stated, namely to meas­ ure the quality of nursing care with regard to patient hygiene. A descriptive survey design was chosen to explore and describe the problem. A check-list was de­ veloped to observe thirty patients (the total population) over a period of one week. The results indicated that certain aspects of hygienic care needed improvement. These aspects (parts) were the care of male patient’s beards; perineal care; and mouth care. Other aspects o f care were indirectly negatively influ­ enced due to incomplete record keeping. On completion of the study recommendations were made with regard to in-service education, management and research. Opsomming Die doel van die studie was om die gehalte van higiëniese versorging gelew er aan pasiënte in ‘n bepaalde hospital in die Kavango, Namibië, te bepaal. Die studie het voortgevloei uit verslaggewing deur die media, koerante en die radio, oor die skynbare gebrek aan higiëniese maatreëls, veral ten opsigte van pasiënt versorging. Om die probleem te kwantifiseer en te beskryf is ‘n enkele doelw it gestel, naam lik om die verpleegsorg van pasiënte te meet, en spesifiek ten opsigte van higiëne. Om die probleem te ondersoek en beskryf, is van 'n beskrywende opname ontwerp gebruik gemaak. Met behulp van ‘n kontrole lys is dertig pasiënte (die totale populasie) oor ‘n tydperk van een week observeer. Uit die resultate het dit geblyk dat sekere higiëniese aspekte aandag moet geniet naamlik die versorging van manlike pasiënte se baarde, perineale versorging en mondsorg. Onvolledige verslaggewing (rekordhouding) het indirek negatief ingewerk op sekere aspekte van versorging. Na voltooing van die studie is aanbevelings gemaak ten opsigte van indiensopleiding, bestuuren navorsing. Introduction and background to the problem Personal hygiene may be regarded as the “self-care” by which people maintain health (Oxford Dictionary, 1990:579). Hygiene is a highly personal matter determined by indi­ vidual values and practices. It is influenced by culture, social, familial and individual factors, as well as by the per­ son’s knowledge of health and hygiene (Young, Van Niekerk & Mogotlane, 2003 :97 -98 ). When people are ill, hygiene practices frequently become 85 Curationis August 2004 secondary to other functions, such as maintaining an open airway, breathing and circulation. They also lack the en­ ergy for simple everyday activities like bathing, or brush­ ing their teeth. This is where the nurse is to support and assist the patient. It seemed that this was not always the case, as the re­ searcher heard negative comments over the radio regard­ ing hygiene care in hospitals in the Kavango region. Some of these comments were that: • Patients were not bathed • Mouth care was neglected • Nails and hair were not cared for, and that the • Environment was not always clean This lead to the following research question: What is the current quality of basic nursing care specifi­ cally with regard to personal hygiene of patients in a se­ lected hospital in the Kavango region? Study objective One objective was stated, namely: To measure the quality of nursing care, with regard to cer­ tain aspects concerning personal hygiene of patients in a selected hospital in the Kavango region. Research design A descriptive survey by means of a checklist was utilized. The population consisted of all the patients admitted to a specific hospital in the Kavango region for a period longer than seven (7) days at a specific time. Thirty (30) patients met these criteria. This was a very specific population that met these criteria, namely hemiplegic patients, HIV/AIDS patients and patients who had amputations. Due to the small population size, all these patients were included with no need for sampling. Thus the total popula­ tion was used. These patients were observed over a period of seven (7) days during which time 210 observations were conducted. The data collection started after the first seven days of hospitalization. A checklist was used as research instrument. The checklist items were formulated based on the objective of the study and the specific information sought. The literature on hy­ giene was studied and the Scope of Practice for Registered Nurses as well as Henderson’s theory on human needs was examined (Namibia, 1993: 1-10; Young et al, 2003:94 95). Relevant aspects were extracted. For validity the checklist was submitted to five (5) regis­ tered nurses who made suggestions were necessary, spe­ cifically with regard to face and content validity The instrument yielded also the same responses when used by a different researcher on the same patient. This was done to determine consistency and accuracy of the instru­ ment as part of an evaluation of the reliability. Pilot study Before distribution, the checklist was pretested. Pretesting was done by selecting five (5) registered nurses from this specific hospital. They were selected purposively because of their managerial positions and clinical skills. These five (5) registered nurses agreed on the type of items and the format of the checklist. They all agreed upon the face va­ lidity of the instrument. Four (4) patients were selected for the pilot study. These four (4) patients were the only patients available during the period of a month before the initiation of the main study that met the inclusion criteria for the population. Only tech­ nical changes like the wording of questions were neces­ sary after completion of the pilot study. Data analysis and interpretation Data to be analyzed contained information on the biographi­ cal background as well as items that evaluated the quality of hygiene and specifically the following aspects: • Hair care • Eye care • Ear care • Mouth care • Nose care • Skin care • Beard care • Hands, nail and foot care • Perineal care These “aspects” were based on the scope of practice . (Namibia, 1993: 1-10) and Henderson’s theory on human needs (Young et al., 2003:94 95). Biographical information Although biographical information was not the focus of this study, it was included because variables such as gen­ der and age might have an effect on the hygiene needs of patients. Twenty six (26) percent of the patients were male, fortyfour percent patients were female and thirty percent were pediatric patients. In this study pediatric patients are re­ garded as patients younger than twelve years. The higher number of females in this study is because it is the function of females to collect water at the river. This is a traditional function in the Kavango region. Unfortunately when conducting this study, a significant number of rebel soldiers from Angola were crossing the river and they also laid antipersonnel landmines. Many of the female respondents in this study were ex­ posed to these landmines, and thus contributed the larger presentation in this study (Observation by the principle researcher). 86 Curationis August 2004 Information on hygiene care The study provided the following results based on the observations of the various hygiene aspects. Hair care Hair care was being evaluated with regard to: • Cleanliness • Shiny or not • Combed or not • Plaited or not Plaited hair is regarded as contributing to overall hygiene in some females in the Kavango region. Figure 2: Outcome of eye care as percentage of total observations (N=30)

To objectively quantify and describe the extent ot this problem, a single objective was stated, namely to meas ure the quality of nursing care with regard to patient hygiene.A descriptive survey design was chosen to explore and describe the problem.A check-list was de veloped to observe thirty patients (the total population) over a period of one week.
The results indicated that certain aspects of hygienic care needed improvement.
These aspects (parts) were the care of male patient's beards; perineal care; and mouth care.
O ther aspects o f care were indirectly negatively influ enced due to incomplete record keeping.
On completion of the study recommendations were made with regard to in-service education, management and research.

Opsomming
Die doel van die studie w as om die g eh alte van higiëniese versorging gelew er aan pasiënte in 'n bepaalde hospital in die Kavango, Namibië, te bepaal.

Introduction and background to the problem
Personal hygiene may be regarded as the "self-care" by which people maintain health (Oxford Dictionary, 1990:579).
Hygiene is a highly personal matter determined by indi vidual values and practices.It is influenced by culture, social, familial and individual factors, as well as by the per son's knowledge of health and hygiene (Young, Van Niekerk & Mogotlane, 2 0 0 3 :9 7 -9 8 ).W hen people are ill, hygiene practices frequently become secondary to other functions, such as maintaining an open airway, breathing and circulation.They also lack the en ergy for simple everyday activities like bathing, or brush ing their teeth.This is where the nurse is to support and assist the patient.
It seemed that this was not always the case, as the re searcher heard negative comments over the radio regard ing hygiene care in hospitals in the Kavango region.Some of these comments were that:

•
Patients were not bathed

Study objective
One objective was stated, namely: To measure the quality o f nursing care, with regard to cer tain aspects concerning personal hygiene of patients in a selected hospital in the Kavango region.

Research design
A descriptive survey by means of a checklist was utilized.
The population consisted of all the patients admitted to a specific hospital in the Kavango region for a period longer than seven (7) days at a specific time.Thirty (30) patients met these criteria.This was a very specific population that met these criteria, namely hemiplegic patients, HIV/AIDS patients and patients who had amputations.
Due to the small population size, all these patients were included with no need for sampling.Thus the total popula tion was used.These patients were observed over a period o f seven (7) days during which time 210 observations were conducted.The data collection started after the first seven days of hospitalization.
A checklist was used as research instrument.The checklist items were formulated based on the objective of the study and the specific information sought.The literature on hy giene was studied and the Scope o f Practice for Registered Nurses as well as H enderson's theory on human needs was examined (Namibia, 1993: 1-10;Young et al, 2003:94 -95).Relevant aspects were extracted.
For validity the checklist was submitted to five (5) regis tered nurses who made suggestions were necessary, spe cifically with regard to face and content validity The instrument yielded also the same responses when used by a different researcher on the same patient.This was done to determine consistency and accuracy of the instru ment as part of an evaluation of the reliability.

Pilot study
Before distribution, the checklist was pretested.Pretesting was done by selecting five (5) registered nurses from this specific hospital.They were selected purposively because of their managerial positions and clinical skills.These five (5) registered nurses agreed on the type of items and the format of the checklist.They all agreed upon the face va lidity of the instrument.
Four (4) patients were selected for the pilot study.These four (4) patients were the only patients available during the period o f a month before the initiation o f the main study that met the inclusion criteria for the population.Only tech nical changes like the wording of questions were neces sary after completion of the pilot study.

Data analysis and interpretation
Data to be analyzed contained information on the biographi cal background as well as items that evaluated the quality of hygiene and specifically the following aspects: • Hands, nail and foot care • Perineal care These "aspects" were based on the scope o f practice .(Namibia, 1993: 1-10) and Henderson's theory on human needs (Young et al., 2003:94 -95).

Biographical information
Although biographical information was not the focus of this study, it was included because variables such as gen der and age might have an effect on the hygiene needs of patients.
Twenty six (26) percent of the patients were male, fortyfour percent patients were female and thirty percent were pediatric patients.In this study pediatric patients are re garded as patients younger than twelve years.
The higher number of females in this study is because it is the function of females to collect water at the river.This is a traditional function in the Kavango region.Unfortunately when conducting this study, a significant number of rebel soldiers from Angola were crossing the river and they also laid antipersonnel landmines.Many o f the female respondents in this study were ex posed to these landmines, and thus contributed the larger presentation in this study (Observation by the principle researcher).

Information on hygiene care
The study provided the following results based on the observations of the various hygiene aspects.

Hair care
Hair care was being evaluated with regard to: • Cleanliness  In 73% observations it was found that the patients' 20 hair had been washed together with the bed-bath.This result must be seen in perspective.During the week o f observations each patient was observed seven (7) times for this particular aspect of hygiene.It is, however, true that many patients may not wash their hair each day.
Although all these patient's hair did not appear to be shiny or combed, they appeared neat and hygienic.

Eye care
Evaluation on eye care was done with regard to:

•
Cleanliness of the conjunctiva  • Eye discomfort Due to the close relationship between inflammatory condi tions and discomfort with hygiene, these two aspects were also included.An example is acute conjunctivitis (pinkeye) which is a common bacterial infection caused by Staphylo coccus, Gonococcus, Pneumococcus, H aem ophilus, or Pseiuiomonas (Sheehy & Lenehan, 1999:441).In only nine (9) percent of the observations, patients with watery eyes were found.Ten (10) percent of the patients expe rienced eye discomfort.
The high incidence of eye inflammation, namely thirty (30) percent is a matter of concern.These findings were however not recorded in the pa tient's records.Therefore, it is very difficult for the nursing personnel to intervene.
A cco rd in g to S earle and Pera (1997: 163), recordkeeping is an essential com ponent of the nursing process, and what is not recorded is not done.

Ear care
The ears were observed for the following: • Cleanliness Due to the possibility o f unhygienic conditions leading to itching with a resultant scratching and damaging, an item of "damage" was also included.Excessive wax build up in the ears could also lead to hearing disturbances, thus this item 's inclusion.The results are graphically displayed in figure 3.
In eighty two (82) percent o f the total observations, the ears of the patients were found to be clean.
In four (4) percent o f the patients, excessive ear wax was found.Also in five (5) percent ear discomfort was observed as well as hearing disturbances in seven percent of the patients.As part of the observations, it was also noted whether the patient's mouth care was attended to at least twice a day.This was only the case in forty eight (48) percent o f the observations.
In sixty (60) percent of the observations, the patients' teeth were evaluated as to be clean.This finding reflects negatively on basic nursing care as one would regard this as a "fundamental" hygiene right of each patient.See also figure 4. Record-keeping was also insufficient, and only in forty four (44) percent of the observations reference to these problems were found in patient records.
The high incidence of halitosis, thirty two (32) per cent, correlates and is connected with the oral dis comfort and unclean teeth.It also affects the patients' general comfort as they may be aware of it as well as their visitors, relatives and health personnel.

Nose care
The nose was observed with regard to the following: • Clean nose  In seventeen ( 17) percent of the observations, the nose was found not to be clean.This is an anesthetic issue because people in contact with the patient may avoid him or her due to this.It might also interfere with the olfactory (smell) sense.

The skin
The skin was observed with regard to the follow ing: All the patients in this study were dependent or semi-dependent on the assistance of the nurse.In eighty three (83) percent of the observations, the patients indicated, and it also appeared evident through observations, that the patients had re ceived a bed-bath.Despite the high percentage obtained, an acceptable norm would be closer to a hundred percent as a daily bed bath is regarded as an absolute minimum requirement.This appar ent shortcoming in providing bed-baths to every patient each day may account for the high inci dence where the skin did not appear to be smooth, namely in thirty eight (38) percent of observations.In all the remaining aspects to be evaluated, a com pliance of above eighty (80) percent was obtained.

Beard care
The patients were observed to see whether their beards were: • Shaved

• Gr(x>med
As can be seen in figure 6, during eighty (80) per cent of the time, the patients were not shaved, despite their willingness to be shaved.
Patient's physical appearance is negatively influ enced when unshaven, especially in the first two days.If patients are not accustomed to it, it may create a feeling of not being "groom ed".

Hands, nail and foot care
The hands, nails and feet of patients were ob served with regard to the following: • Nails (short and clean) The fact that most of the people in the Kavango region walk bare feet could be the contributing factor of inflamma tion as also is indicated in figure 7 Perineal care During this part of the hygienic evaluation, observations were done with regard to: ily result when hygienic care is sub-optimal, even the slightest deviation should be noticed (Sheehy & Lenehan, 1999:327) • Presence of abnormal discharge.Although few abnormal observations were noted as can be seen in figure 8, the researcher did, however, notice the following:

•
Perineal care was not done during the bed bath; and • Nothing was recorded.
As the spread of micro-organisms to the bladder could eas-This is even more important due to the fact that many of these patients already have full blown AIDS and their immune system is severely com promised.

Appropriate nursing actions taken
Patients' records were scrutinized to confirm if appropriate nursing actions were taken.As can be seen in figure 9, this was not the case.If noth ing was recorded, it was regarded as not being done.
According to Searle a nurse betrays the relation ship with her patient when she is lax in maintain ing records (Searle, 1991: 86).

Recommendations to improve the quality of hygienic care
Recommendations were made with regard to in-service edu cation, nursing management and further research.

In-service education
Education is defined by Mellish & Brink (1996:76) as a proc ess of leading the person being educated from a state or not knowing, to a state of knowing.In-service education refers to training received by the nursein practi tioner inside the working environment and which is directly related to the work (Muller, 2002: 344).
Following this study it is recommended that all categories of nurse be subjected to in-service edu cation programmes.This will enable them to bet ter integrate theory and practice.
Emphasis should be placed on responsibility and accountability as is deducted from the scope of practice as stipulated in the Nursing Act, Act No. 30 of 1993(Namibia, 1993:1 -10).
Furthermore it is necessary to instill a caring atti tude or philosophy.It is the perception of the re searcher that some o f the inadequacies in hygi enic care could be attributed to a lack o f care.As Watson put it: "The practice of caring is central to nursing" (Watson, 1995:318).

Nursing management
The m anagem ent of patient care needed to be strengthened.It was observed during this study that a lack of supervi sion existed based on the fact that auditing of patient files was not done.Consequently nursing actions taken could not be compared to the expected outcome.Thus it is rec ommended that regular patient record audits be done.
It was also recommended that regular quality control meet ings be held between managers and registered nurses.

Further research
It was recommended that patient evaluations be done be fore discharge in order to obtain patient assessment of the quality o f care.A public relation officer could be appointed, made known to the public, to whom the members of the community could go with their concerns.As this study was limited to one hospital, it is recommended that similar studies be done in all the hospitals in Namibia.Further studies should also be conducted during which time standards could be formulated.

Limitations of the study
There were limitations with regard to the study population as well as the working environment.

The study population
For this study to be effective a minimum number of patients were required in order to obtain reliable statistical data.
These patients had to be observed for a period of at least seven (7) days each.As this is an endemic malaria area, patients may be admitted only for 3 -4 days and then will be discharged.Thus a very specific population was studied, namely hemiplegic patients, HIV/AIDS patients and patients who had had amputations.

Working environment
The political instability in Angola caused an extra burden on the workload of the nurses.All the war victims in An gola as well as in Namibia were referred to the regional hospital where the study was conducted.This could have created an additional physical and emotional burden.

Conclusion
The results of the study highlighted some shortcomings in hygienic care.These shortcomings are regarded as easily rectifiable by means of in-service education and optimum management by the nursing managers.Quite often, as pects of care were indirectly negatively influenced by a lack of proper recordkeeping.This aspect has legal implica tions and should also be addressod in earnest.

Figure 2 :
Figure 2: Outcome of eye care as percentage of total observations (N=30)

Figure 1 :
Figure 1: Outcome of hair care in percentage of total observations (N=30) Figure 3 : Outcome of ear care as percentage of total observations (N=30)

Figure
Figure 4 : Outcome of mouth care as percentage of total observations

•
Nose discomfort • Damage to the nose • Abnormal discharge Due to the dry climate in Namibia, it might create a drying effect on the nasal m ucosa with a resultant

Figure
Figure 5 : Outcome of nose care as percentage of total observations (N = 30)

FigureFigure 7
Figure 6 Outcome of beard care as percentage of total observations (N = 30)

FigureFigure 9
Figure 8 Outcome of perineal care as percentage of total observations (N = 30) GORD O N , D; LARSON, T J & M CG U RK , C R 1981: The Kavango peoples.Studien zur kulturkunde.Wiesbaden: Franz Steiner Verlag.NAM IBIA (R EPU B LIC ) 1993: Government Gazette of the .