We will test the hypothesis that a behavioural change intervention to improve hand care, based on the theory of planned behaviour and implementation intentions, coupled with provision of hand moisturisers, can produce a clinically useful reduction in the occurrence of hand dermatitis when compared to standard care in at-risk nurses working in the National Health Service (NHS). Secondary aims will be to assess impacts on participants’ beliefs and behaviour regarding hand care. In addition, we will assess the cost-effectiveness of the intervention in comparison with normal care.
As participants in both the ‘intervention’ and usual care sites will receive an intervention, the principal intervention will be known as intervention plus and the usual care will be known as ‘intervention light’. Intervention plus will centre on a bespoke on-line behavioural change package (BCP). Members of the study team will develop this with expertise in dermatology, occupational medicine, nursing, and health psychology and care will be taken to ensure compatibility with current guidance on infection control. It will include advice: on when and when not to use gloves; on when to use antibacterial hand rubs; on when to use moisturising cream; and to contact OH early if hand dermatitis occurs. As part of the package, nurses will be asked to form implementation intentions for performing behaviours in their workplace. These will be recorded, and participants will subsequently be reminded of them and offered the opportunity to revise them. Provisions to encourage adherence, such as moisturising creams, will support the package. It will be actively reinforced over the course of the study by consistent messages on skin care from local OH and control of infection teams, and from line management.
We will test the interventions in a cluster randomised controlled trial at 35 NHS hospital trusts/health boards/university occupational health departments (‘sites’) , focusing on two groups of staff: (i) student nurses who are about to start their first clinical placements, and are at increased risk of hand dermatitis from wet work because of a past history of atopic disease or hand eczema (18 sites) and (ii) nurses working in intensive care units who are at increased risk of hand dermatitis because of the nature of their work (30 sites)
Nurses at ‘intervention light’ sites will be managed according to what would currently be regarded as best practice, with provision of an advice leaflet about optimal hand care “Dermatitis: Occupational aspects of management. Evidence-based guidance for employees” (also provided to the intervention plus group, and developed by Health and Work Development Unit, Royal College of Physicians) and encouragement to contact their OH department early if hand dermatitis occurs. However, they will not receive the BCP or active reinforcement of its messages. Nor will they routinely be offered supplies of moisturising cream over and above what is already standard practice in their site.
The impact of the interventions will be evaluated from information collected by questionnaires, standardised photographs of hands/wrists (which will be assessed for the presence of dermatitis blind to other information about the participant). In addition, we will assemble relevant economic data for an analysis of costs and benefits, and collect information from various sources to evaluate processes.
Statistical analysis will be by multi-level regression modelling to allow for clustering by site, and will take account of the paired nature of before and after comparisons in individuals.
The principal outcome measure will be the difference between intervention plus and intervention light sites in the change in point prevalence of visible hand dermatitis from baseline to 12 months after the intervention as assessed by the study dermatologists.
Secondary outcome measures will include:
The difference between intervention plus and intervention light sites in the change in the prevalence and severity of visible hand dermatitis from baseline to the end of follow-up as assessed by the study dermatologists
Days lost from sickness absence and total number of days of modified duties because of hand dermatitis per 100 days per year of nurse time during the 12-months of follow-up as indicated in the study questionnaires
The change from baseline to after completion of the BCP, and to the end of the 12-month follow-up in beliefs about dermatitis prevention behaviours.
The change from the baseline to the end of follow-up in dermatitis prevention behaviours relevant to skin care.
The change from baseline to the end of follow-up in quality of life score
The use of moisturiser provided for the intervention (in terms of requests for further supplies by student nurses and orders for supplies of moisturisers by ICUs).