Hand washing is vital to prevent the spread of infection, especially in hospitals – but for young children, exploration is all about using their hands. Isobel Manning explains about a unique project in which children at Great Ormond Street Hospital explore the meaning of micro-organisms and hygiene.
When was the last time you washed your hands? Do you wash them often with warm water and soap, or just whisk them under a cold tap after going to the loo?
Today the hand washing message packs a punch. With alcohol gels and state-of-the-art hand dryers, washing your hands is no chore: it is often a novel experience. As we are increasingly made aware of the health risks associated with poor hand hygiene, this particular pattern of human behaviour is becoming ever more instinctive, a ritual embedded in the working life of many professions.
Images of menacing, troll-like germs dance about in TV advertisements for intensive high-powered cleaning products, as we are encouraged to leave no fingernail unturned. There are also enormous global campaigns to inspire some of the most poorly sanitised communities to use soap and wash their hands, helping to prevent cholera outbreaks and death by diarrhoeal diseases.
With a rich cultural history, hand washing is also a symbolic action, a way of purifying the soul and a ritual that has been practiced religiously for thousands of years. Since the claims of Dr Ignaz Semmelweis and the discovery of micro-organisms, we have developed significant biomedical evidence that ‘clean hands are healing hands’; appropriate hand hygiene is now standard protocol for infection prevention and control in hospitals and one of the most effective ways of reducing cross-contamination.
Children, in particular, are a major target for ‘wash your hands’ promotions. Many parents carry antibacterial wipes with them wherever they go, conducting regular front-to-back hand checks. In schools, teachers instruct hand washing intervals throughout the school day. Some even time their pupil’s hand washing with a stopwatch, and in Jewish schools a special cup is provided for the pupils to perform their Netilat Yadayim,a custom that involves pouring water over the hands three times.
Although some parents are faced with challenges in convincing their children that hand washing is a good idea, generally young people today are pretty well practiced in the procedure. To what extent do children understand why they wash their hands? Is their hand washing effective? Are we teaching them to be overly concerned with cleanliness, without first explaining the reasons why we wash our hands?
Developing creative projects with patients at Great Ormond Street Hospital, I became aware of a paradox between the instinctive need young children have to investigate their environment and the acute implications of spreading infections through this physical ‘hands on’ exploration.
Hands are seen as the primary organs for physically manipulating the environment. With the fingertips containing some of the densest areas of nerve endings on the body, our sense of touch is intimately associated with the hands. Young children’s hands appear delicate and unscathed by a world that will later shape and be shaped by them. Just beginning to feel and examine, they use their hands to reach out beyond themselves, to communicate and understand, quickly enticed by the pleasure of getting dirty.
Some patients I visited had been inpatients for some time, living in closely monitored conditions, many unable to move from their rooms. Infection prevention and control is crucial in this environment, with intricate filtration systems built into the architecture, releasing or securing harmful airborne pathogens. Hospital staff adhere to rigorous guidelines of precisely how to wash one’s hands, with nurses recorded as washing their hands once every three minutes.
Adapting to the hospital environment has an impact on these young people. They closely observe the behaviour of their nurses. One young patient told me that she watches when the nurses wash their hands, and if she hasn’t seen them washing their hands before treating her, she will tell them to do it.
The ‘Hands On’ project is part of the arts programme at Great Ormond Street Hospital. It looks to discover what hand washing means to young patients at GOSH, as well as encouraging them to learn in more depth why they wash their hands by investigating the microbiological, historical and cultural associations of hand washing.
Over the past six months I have developed and delivered a programme of innovative, creative and interactive workshops throughout the hospital, working with long- and short-term patients from 6 months to 17 years old. With the support and expertise of medical staff and microbiologists from the hospital’s Infection Prevention and Control Team, the project will result in an animated film about hand washing made by the young patients, which will be screened in September.
With just a little bit of nose picking, quite a lot of smirking and a few words about poo, the children and I have many entertaining conversations. The younger children thought about what we find underneath the skin on hands, why we have bones, nerves, etc and how we are able to pick things up, touch things and know what they feel like. When I asked Amy (age 4) what she thought her hands were made of and what was under the skin, she said “they are filled with soap”. Analease (age 5) said that without bones in our hands “we couldn’t drive a car or play with our friends”.
Some of the older children designed their own micro-organisms. Tresmitis was a type of bacteria that liked to live in hair and also wore a hat! Rachel (age 12) named her made-up-microbe Antidisestablishliceterianism! These young people learnt about microbiology and the types of organisms that exist without us necessarily being able to see them. They gained a more informed perspective of ‘germs’ and an understanding of the significance of micro-organisms to the environment by taking samples from themselves and the objects around them. They considered more philosophical questions about hand washing.
When asked, “Do you think people have always washed their hands?” Garret (age 10) said “No, no, not for cave men… Because did you know that real men actually come from gorillas? … Gorillas and humans are the only animals that have opposable thumbs.” David (age 10) told me how he washed his hands with a washing cup. “It has two handles … we use the same one at school.” David went to a Jewish school and said, “we wash our hands before lunch,” and his mum added: “before eating bread”. He also said that “sometimes (people wash their hands) for OCD”.
For some very young children, just making their hands sticky, sparkly and colourful has been enough to make them think about washing their hands. Some children even took themselves off in the middle of a workshop to go and wash their hands. From the fastidious to the lackadaisical, the children’s take on hand washing has at times seemed logical and at others completely absurd.
One young boy I spoke to, who was an outpatient (I could not possibly mention his name for fear of dobbing him in!) told me, secretly, that to avoid actually having to wash his hands he would go to the bathroom, spit on his hands, rub it in and return to his teacher holding out his hands, with their damp, just-washed appearance.
Isobel Manning is artist in residence at Great Ormond Street Hospital. Find out more about the Hands On project at www.thehandsonproject.blogspot.com. The project was supported by a Wellcome Trust Arts Award.