The aim is to clarify some of the terms used and help practitioners create their own routines and procedures. However, always follow your setting’s advice, seek guidance from your regulatory bodies and national government in the first instance.
The article is a joint effort by Juliet Robertson and Jason Tetro, a hygiene researcher at Ottawa University. He writes an upbeat blog The Germ Guy which will give you lots of useful information. Thanks Jason, for all your input and advice!
- How many times you have washed your hands today?
- For how long did you wash your hands? The recommended minimum time is 15-20 seconds or the time it takes to sing “Happy Birthday”.
- Did you follow the correct procedures? This includes proper rinsing and drying.
- Did you use handwipes or santisers?
If you answered “Yes” to the last question, there may be a problem.
Health Protection Scotland have issued this statement:
“Hand washing is a learnt behaviour and therefore children need to recognise when to wash their hands and understand why it is important to wash their hands correctly. To do this they need help from their parents, carers, teachers and adults in the childcare setting. Based on the assessment of the literature and the summary above, the following recommendation is proposed for hand hygiene in the outdoor nursery setting:
Hand washing with soap and running water should be performed:
- After using the toilet/changing a nappy
- Before and after eating, drinking or preparing food
- After sneezing, nose blowing or coughing
- If hands are soiled/dirty
- Before going home”
On the surface, this advice looks quite straightforward and sensible. I’m sure almost all of us would agree that good hygiene routines and practice is essential in any nursery, indoors or out. Soap and running water is best. It’s natural and it’s effective when hands are washed carefully and properly.
Underneath the surface this statement adds to the confusion, chaos and uncertainty surrounding best practice in outdoor hygiene. It is worth noting that to-date there has been no recorded outbreak of E.coli or any other infection associated with fecal-oral transmission in any UK outdoor nursery. This is the main concern over hand hygiene. Scotland has a high and rising rate of E.coli infections compared to other EU Countries. As a result, outdoor nurseries have been allocated the same health and safety standards used when on farm visits rather than standards applied to nurseries on an off-site trip. This purports fear, paranoia and a lack of understanding about the benefits of outdoor nurseries and the actual risks of attending one.
The HPS advice is for outdoor nurseries. If you are a regular nursery or a school the advice does not necessarily apply, but it’s worth taking notes and adapting practice as needed. Most importantly, schools and settings should not feel that they must stick to trips where public toilets are in the immediate vicinity. Children need to learn to manage toileting, handwashing and other personal hygiene where such facilities do not exist or do not work. For expeditions and many walks, it is unreasonable and impractical to have to have a place with running water facilities every half a mile or so. Imagine what Ben Nevis and all our other Scottish hills would look like with taps installed at regular intervals up the paths!
Hand hygiene advice for outdoor learning practitioners
What is “Running Water”?
By running water, this means fresh, clean water that is not stagnant. It can come from a bottle. It does not have to come from a tap. There has to be low turbidity, low levels of organic carbon, no evidence of microbial growth and have either a pleasing or no odour. This is fairly common sense when it comes to water. Cross-contamination needs to be avoided. Thus the good old-fashioned bowl on sticks at Scout camps in the Seventies is now a no-no, according to infection control specialists.
Likewise, each child must carry their own personal hand towel for drying their hands or use paper towels. This does debunk the myth that running water and soap is less wasteful than handwipes outside.There are many ways of purifying water such as evaporating and distilling it. This should not be necessary on day trips but may be a consideration for multi-day expeditions or school visits to some countries. There are many different types of filter pumps on the market. Antimicrobials such as ethanol, chlorine and chlorohexidine gluconate can be added. Advice should always be sought from your local authority outdoor education or health and safety team over use of purification methods.
In remote locations where running water is not available, the health and safety advice is to take reasonable, practical steps to minimise the risk. The definitive guide is the World Health Organisation Hand Hygiene Guidelines. This is an interesting document in that there are not blanket tatements but advice which includes the need to take account of local cultures and contexts. In Section 10.3, the guidelines state the need for better research methods, particularly in relation to ordinary circumstances rather than laboratory controlled experiments. A good example of an alternative approaches taken in other countries is the use of tip taps, as can be found on the Cow Files website.
In the absence of “normal” running water, we have to look towards other sources, even if they are different from the norm. Perhaps it’s less about the running water and more about the fact that our environment is so naturally contaminated that we believe we need a human factor to ensure safety. We need to take a more ecological view.
What are the issues with sanitisers?
Alcohol based rubs and sanitisers are only effective on clean hands that have no visible contamination. Essentially they make clean hands ultra clean! Research from Ottawa University in combination with the national media organisation, the Canadian Broadcasting Corporation (CBC) suggests that the 99% claim on the package is only in lab tests and that effectiveness in the real world is 50-60%, whether the active ingredient is alcohol or another antimicrobial chemical. Moreover, hand sanitisers work best to remove bacteria, viruses and fungi that are transient on the skin, that is, they can be spread easily through touch. If hands are grossly contaminated, hand sanitisers will not be able to return hands to safety as there needs to be friction and pressure to remove the contamination from the skin. The use of a wetted fabric such as towel or wet naps and/or nappy wipes works well.
There are some cultural issues associated with hand sanitisers. These focus on the use of alcohol rather than risks around ingestion. There are a plethora of non-alcohol based sanitisers that have a longer lasting effect in terms of disinfection and come in foam spray that allows visible contamination to be removed at the same time. For further advice here, contact Toyguard, a Scottish pre-school hygiene company who clean up after E.coli outbreaks in Britain, including nurseries. They use biodegradable products from Scandinavia.
What about handwipes?
There is evidence that people get their hands cleaner when using wipes. They wash/wipe closer to the 15 seconds minimum recommended time. It’s best to use 2 wipes – one to remove the visible contamination, the other to get the hands really clean. Furthermore, research in hospitals suggests that workers are more likely to use waterless hygiene products than wash their hands because it is more convenient. It is fair to assume that the same situation would apply in terms of people’s preferences and behaviour, particularly in a cooler climate such as Scotland where water is very cold most of the year round.
However, the long term effects of using wipes are purportedly unknown. This is why running water is insisted upon by HPS. It may seem like a strange assumption given that thousands of babies’ bottoms are wiped daily for over two years whilst having their nappies changed. Most of these babies have not suffered any ill effects. Those that have, the parents switch to another cleaning method. For children to wash their hands in the correct manner for 15s at a time, supervision is usually required, taking time away from other activities. In winter when the temperatures go down, the body chill times go up. So, the use of running water outdoors becomes debatable when used continuously as a measure. It also means that a significant amount of time is consumed with handwashing.
What about parental viewpoints on hand hygiene?
Returning to HPS advice on hand hygiene, it is recommended that settings inform parents about hand hygiene risks, procedures and practice outside – both within the designated outdoor space and for off-site trips as well as indoors. If a parent insists that soap and water is used instead of handwipes then staff should comply with this request.
The main points to remember
- Ensure advice is available to parents about hand hygiene outdoors in the designated space and for off-site trips. Parents should know that they can request their child uses soap and running water at all times and staff must ensure this happens.
- Consider hand hygiene in school grounds or outdoor space. Can children easily access running water and/or handwipes? What happens to the paper towels and hand wipes, once used? Is there a bin or bag nearby? Create a “sniffle station” for these items to be placed together!
- At all times, encourage children to use the proper techniques for getting hands really clean and eventually being able to do this independently of adults.
- If your setting uses handwipes and/or sanitisers, think carefully about the types which are most suitable and seek advice here.
- Schools and nurseries can still visit places where public toilet facilities may not exist. However, this should be put in your risk benefit assessment and clear routines and procedures must be in place that all staff, volunteers and children know and can easily follow.
- Always take a large bottle of clean water, soap and some paper towels on a day trip, even if the decision to use handwipes has been taken. In the event of a child getting very soiled hands, then the water can be used.
Finally I’d like to thank the staff, parents and children at the Secret Garden Outdoor Nursery for their persistence, determination and courage in addressing this matter proactively. As Margaret Mead once said:
“Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever does.”