Hand hygienization: a playing activity in care patient safety

To describe a ludic health education strategy on hand hygiene and its interface in patient safety in the hospital environment. Report of play activity with a view to health education held from March to June 2018. Participated 485 professionals from 18 units of a hospital in the west of Santa Catarina. It was developed focusing on the five moments proposed by the World Health Organization: before touching the patient, before the aseptic procedure, after risk of exposure to body fluids, after contact with the patient, after contact with the areas close to the patient. The professionals participated in the proposal experiencing moments of relaxation, learning, reciprocity and creativity. This potentiated the change in hand hygiene technique. The use of ludic provided reinforcement and apprehension of the contents worked, arousing feelings of co-responsibility.


Introduction
The supervised curricular internship (SCI) is a mandatory curricular component of Graduation Nursing courses. It is a tool that gives students the opportunity to consolidate knowledge, skills and attitudes in the dimensions of assistance, management, education and research. Its development provides a living laboratory for those involved in the teaching-learning process, which strengthens the skills for work in health institutions. It aims to lead the student to the articulation of theory and practice in a participatory training process, permeated by the dialogue between teaching and learning in extramural environments, with the active participation of service professionals, the university and the community. 1 When planning the necessary actions for the work environment, the student has the opportunity to reflect on the current paradigms and internalized beliefs. Such circumstance will promote reasoning, perception and sensitivity, allowing to propose measures that will strengthen the service and the health system, which contributes to academic and professional improvement (MARRAN; LIMA and BAGNATO, 2015).
During the internship, at the Serviço de Controle de Infecções Relacionadas a Saúde (SCIRAS -Control Service of Health Related Infections), actions related to hand hygiene were identified as a priority. In view of this need, the trainee of this service together with the professors and professionals of the service developed a project to raise awareness among hospital staff about the importance of hand hygiene through playful activities.
Hand hygiene is recognized worldwide as a primary, simple and effective measure in the control of Infecções Relacionadas à Assistência à Saúde (IRAS -Healthcare-Related Infections (HAI)). For this reason, it has been considered as one of the pillars of prevention and control of infections in health services, including those resulting from the cross-transmission of multi-resistant microorganisms (BRASIL, 2009;BELELA-ANACLETO;PETERLINI and PEDREIRA, 2017).
In this context, performing hand hygiene during professional health activities contributes to the prevention of HAIs as it constitutes an opportunity to interrupt the main form of pathogen transmission, that is, direct contact between the caregiver, the patient and the environment. assistance, a situation that promotes the safety of hospitalized patients.
The subject of patient safety has occupied a prominent place in healthcare spaces and has become an emerging challenge for researchers in the field and professionals, as it provides for the reduction, or elimination of errors and adverse events resulting from care processes (BRASIL, 2013).
As a result, nursing plays a predominant role in terms of mitigating existing risks in hospitalization, seeking better care and management practices, aiming to achieve the patient safety goals proposed by the World Health Organization (SIMAN and BRITO, 2016).
Thus, the objective of this article is to describe a playful health education strategy on hand hygiene and its interface in patient safety in the hospital environment.

Methods
The development of the health education action took place at the Hospital Regional do Oeste (HRO -Western Regional Hospital), located in the west of Santa Catarina, from March to June 2018. The proposal is linked to the project "Mãos Limpas" (Clean Hands) of the State Health Secretariat of Santa Catarina. Participated 485 professionals from the three work shifts in the 18 inpatient, emergency care and outpatient units, as well as in the pharmacy, laboratory, nutrition and dietary services, in the human resources sector, purchasing, maintenance, hospitalization, hygiene and laundry, nursing management and administrative area. In addition, students from uni and multiprofessional residencies were contemplated.
The educational activities were carried out by the student supported by SCIRAS professors and nursing staff. Initially, the proposal was studied by reading articles, for appropriating the theme, and choosing the dynamics that met the outlined objective. It was decided to develop a playful proposal for educational action.
To this end, costumes were made that referred to soap and hand, replicas of the figures used in the campaign of hospitals in the Ebserh network (Rede de Hospitais Universitários Federais -Federal University Hospitals Network). The characters included the bacteria called "Regionella" in reference to the name of the institution. Still, in order to make the proposal more attractive, a song was chosen referring to hand hygiene, which would arouse the interest of professionals in the places where the characters would pass and motivate the audience present. The selected song was: "Lavar as Mãos" (Wash the Hands) by Arnaldo Antunes.
Thus, one arrived at the units singing and the nursing intern interposed the use of costumes with techniques. In the units, the person in charge of the sector was asked to bring the team together so that it could be briefly discussed about the importance of Hand Hygiene (HH). During the dynamics, the routine of HH was clarified to patients and companions, stating that everyone should perform it properly, as the attitude surely benefits patients.
In the course of the activity, a field diary containing the observed positive and negative points was provided, aiming at improving the strategy used, consolidating the HH procedure and strengthening the patient safety culture in the hospital.
It was decided to carry out a playful educational strategy to promote the involvement and interest of all participants with free expression and to stimulate reflection and debate, as well as, awakening the feeling of co-responsibility for the proposed measures.

Results and discussion
The dynamics developed with the health professionals made it possible to involve the teams with fun and joy. It was a different, relaxed activity, free of charge, being a fun way to teach and value know-how. The educational activity developed at the hospital was characterized by the expression of words of satisfaction, hugs, laughter and gratitude for being able to learn while playing and active and interactive participation throughout the learning process. It allowed the professionals working in the service to interact with the promoter team, strengthening the bond between intern, SCIRAS and the team of professionals, bonds that are difficult to be established in a daily routine of demands and impositions.

Figure 1. Photo of the Health Education Team.
Source: Photo extracted from the archives of SCIRAS Playful learning strategies are an innovative and creative option because they associate a relaxed and fun character to the process, which tends to capture people's attention to something that is intended to reflect, analyze and or raise awareness. Although playful practices are strategies usually thought for children, it is certain that adults can also benefit, considering the pleasant effects that arise in front of them.
The experience shows that its application/utilization in the most varied scenarios of health care services is feasible since it acts fundamentally by reducing stressors, minimizing anxiety and anguish present in the hospital environment, in addition to allowing the free expression of feelings and communication. Furthermore, it is intrinsically related to moments of physical, mental well-being and interpersonal interaction, demonstrating that a transformation in know-how can occur, in addition to strengthening self-esteem, autonomy and reflection for a better understanding of the topic under discussion (PINHEIRO and GOMES, 2014).
Based on these statements, it appears that learning can be facilitated by playful activities that rescue creativity and joy, helping people to overcome everyday difficulties. Thus, learning about hand hygiene, an essential practice in a health service, can be seen as rewarding and facilitating know-how.
Working on the importance of hand hygiene with the role of a character representing a bacterium, materializing the microorganisms in the hospital environment, which can be extremely harmful to the patients' organisms, made possible an awareness of the effective need to hand hygiene for in realistic, attractive and striking health care. The expectation is that the hospital service worker will be more sensitive to this practice, which emits security to health care, as it tends to associate fundamental technical learning and health security with the materialized and fun memory of the patients lifethreatening microorganism.
In this case, it is possible to conjecture about the relevance of ludic activities for health learning, regardless of the age group, since playing, telling stories, and dramatizing leads to pleasant moments, as well as, can fill gaps in the construction of knowledge about the theme being worked on. Thus, playfulness is a potential educational strategy for which inclusion in educational projects and service training should be encouraged, as an active process that transforms everyone through fun, motivation, aesthetics, such as laughter, tear, emotion (MORAES, MACHADO AND VALENÇA, 2011).
In this view, working with the ludic is not abandoning the serenity and the importance of the contents, on the contrary, it is favoring the strengthening of the apprehension of the contents, developing the imagination, the fantasy and the feelings.

Conclusion
The report of this experience in which the ludic hand hygiene strategy was used, had a noticeable impact on the professionals of the hospital, having been a major factor in the positive results observed.
Health professionals, in general, have contact with health education strategies through lectures, videos and even demonstration of the correct technique since it reduces the infection associated with health care. All these methods are undoubtedly relevant, however, it is an indisputable fact that the ludic strategy is irreplaceable as a stimulus for the construction of new knowledge and strengthening of the skills already acquired. When using this technique, it was found that those involved learn and learn with pleasure, strengthening the development of cooperation and integration in the service.
The choice of playfulness also motivated the professionals involved in the preparation and organization of the activity, transforming what is daily routine, such as hand hygiene, into a conscious and responsible action, with a direct impact on care, carrying out health education and changing habits correctly, thus rescuing the essence and importance of HH in health care.
Therefore, initiatives like this, which combine scientific knowledge of a practice with pleasurable sensory stimulation, tend to mark significantly the professionals who experience it.