HCAI Prevention Through Hand Hygiene

1.0 Introduction

From time immemorial, healthcare-associated infections (HCAIs) have been a problem for healthcare facilities all over the world. In fact, Health Protection Agency (2012) estimates that 6.4% and 7.1% of hospitalised patients in England and Europe respectively develops HCAI. Besides, the same statistics indicate that in Europe, at least 37,000 patients die as a result of health complications associated with HCAI. Interestingly, it is estimated that between 15% and 30% of HCAI are avoidable through implementation and compliance with existing interventions, most of which are standard precautions (National Audit Office 2009). Fuller et al (2011) insist that health hygiene is the most highly regarded standard precaution for the prevention and control of HCAI whose level of compliance can be poor. This observation is confirmed by (Chau et al 2011) who found a poor level of compliance to glove use. Besides, Girou et al (2004) established an association between glove use and hand hygiene in an observational study that involved 120 health workers, where they observed that 64% of the participants adopted improper use of hand gloves thereby not observing hand hygiene. For those needing further insight into these issues, healthcare dissertation help can provide valuable guidance in exploring effective strategies for improving compliance and reducing HCAIs.

When patients within the hospital setting are exposed to heavy antibiotic use while in constant contact with healthcare staff, there emerges a risk of cross-infection especially when safety precautions such hand hygiene are not maintained (Flaherty & Weinstein 1996). Yet, according to Flaherty & Weinstein (1996), antibiotic resistance increases the mortality and morbidity associated with a prolonged hospital stay, thereby increasing the cost of healthcare. In fact, literature by The Review on Antimicrobial Resistance (2014) indicates that while it is possible to acquire a second or third line treatment for patients who have developed antibiotic resistance infections, the costs of treatment for such drug-resistant infections are estimated to cost NHS around 180 million pounds a year. These daunting costs associated with HCAIs calls for effective remedies to ensure compliance with safety precautions such as hand hygiene in view of reducing HCAIs. Hence, the main aim of the proposed project is to develop an educational intervention to improve hand hygiene and compliance in the hospital setting.

2.0 Literature Review

In an attempt to evaluate quality research evidence on hand hygiene compliance and education as an effective intervention to improve such compliance in a hospital setting, the following section entails a critical literature review of journal articles retrieved from credible academic databases through a process that is described in Appendix 2. Here, the researcher will use the Cormack’s Critiquing Framework to critically analyse pieces of evidence from journal articles and literary materials comprising of primary research, local and national policy as well as a range of relevant resources.

The researcher clearly and concisely describes the topic of the study, stating their intention of identifying how education can contribute to the control and prevention of HCAIs. The title is indeed informative because, from the first glance, any reader can understand that HCAIs can be controlled and prevented and that one of the interventions for achieving that is through education. Besides, the tittle is written in such a way that a reader would know the paper’s content i.e. infection control and education. Lastly, it is commendable to note that the title gives a clear indication of the research approach because the author has explicitly indicated that the paper is a literature review. Unfortunately, there is no clear indication of the author’s academic qualifications as well as any mentioning of the professional qualifications/experience wielded by the author. This does not only make it difficult to establish the author’s capacity, credibility an ability to conduct the study but also makes it difficult for any reader to establish the validity of the study. Nonetheless, it is important to note that the author has provided contact details that could enable anyone seeking such information to make a request.

The author has developed an abstract that not only identifies the aim of the study but also describes the findings of the study. Unfortunately, the researcher’s abstract does not identify the research problem and therefore fails to set the scene, form the start, of the problem he is trying to solve. Yet, Bryman (2016) argues that it is important for abstracts to highlight the problem under investigation so that readers can know from the start of the paper the problems they are seeking solutions for. While the researcher has also failed to state the hypothesis, there is no offense with this because the study did not involve any hypothesis to be tested. However, we appreciate the fact that the researcher has clearly mentioned the study methodology he intends to use, as well as details of sample studies he intends to use (i.e. studies focusing on education as an intervention for improving compliance with safety precautions). Ultimately, in the abstract, the researcher has given a clear and precise description of the study findings and conclusions, and this helps any reader to quickly identify the results at a glance (Dawes, 2005). In the introduction section, the researcher has clearly defined the problem under investigation, by highlighting that HCAIs have had a massive impact on the delivery of health services, affecting patients and leading to high cost of healthcare delivery for NHS. Besides, the author indicates that the UK legislation on health care (Health and Social Care Act 2008) requires healthcare systems such as the NHS to establish training and education for Healthcare staff as one of the interventions for addressing HCAIs. Against this backdrop, the authors have clearly stated the rationale of the study, which informs further research on infection control education both for practicing midwives and nursing students. More importantly, the researchers have stated the scope and limitations within which the study will be carried out, highlighting that the literature review will be limited to studies in English language, studies published after 1995 and before 2009, studies specifically addressing midwifery or nursing, and studies based on research papers. This articulation of research scope and limitation is important in informing the reader what might be covered and what might not be covered within the study.

Bryman (2016) states that there is a need for researchers to define every concept they use in their studies, as well as how they are operationalized in that particular study. This enables readers to examine the validity and reliability of the variables or concept – identifying whether the concepts really mean what the researcher is refering to. In Ward (2010) the researcher has clearly defined the key concepts and variables in the study, including HACIs and education. A clearly defined methodology does not only help in verifying the reliability and relevance of the study but also allows for the replication of the study for any other researcher who would want to. Considering the study by Ward (2010), there is a clear statement of the research approach to be used- a literature review. It can also be easily extrapolated that the research method of a literature review is appropriate for the particular problem the researcher is trying to solve, which is to inform future research on education as an effective intervention for improving compliance to safety precautions against HACIs. By conducting a literature review, the researcher is able to inform future research because the process, what is known about the topic, as well as existing research gap, is identified.

The researchers have also successfully identified the several limitations inherent in their study, including the fact that they the study only drew literary materials from two databases, meaning that some important studies from other databases were left out. The study also excluded literary materials written in other languages apart from English, yet these could have also been possible sources of useful evidence. Chalmers (2012) insists that the sample selection approach in any type of study is important in determining the reliability of the study because each type of study has its own appropriate sample selection criteria depending on the study objectives. In the current study, the researcher has developed elaborate criteria for the selection of studies to be included in the literature review. The fact that the researcher selected studies with a background in Canada, Europe, South America, and even Asia means that there was a clear thought process employed in the study – making it more reliable. The researcher has also clearly stated the sample size i.e. the number of studies selected from each of the aforementioned regions.

The researchers have also clearly described their data collection procedure, using a data extraction tool that identifies the study reference and location, the study design and sample, the setting within which each study was conducted, the key findings of each study and the author’s comments regarding the study. According to Denscombe (2012), using such a tool to describe how data was collected from literary materials not only provides sufficient information on the sources of data but also provides an opportunity for readers to conduct further interrogation and verification of study findings. However, it must be noted that the researcher has failed to identify and evaluate the validity and reliability of the instruments used by the respective studies to achieve their findings. This leaves readers speculating about how the respective studies arrived at their findings, and whether such findings can be used to make accurate inferences in the current study. Being a literature review (i.e. secondary research), the study did not involve any human subjects and therefore there was no need in identifying or mentioning the ethical considerations during the research process. The researcher has also not mentioned any ethical issues highlighted in the reviewed studies, hence it is impossible to establish whether the entire study was based on ethical grounds. This affects the reliability of the study because regardless of whether it is a secondary study or primary study, there is a need to make relevant ethical considerations based on each study methodology.

De Brun & Peace-Smith (2009) argues that the results section of any study is one of the most informant sections and therefore it must be presented in a clear and concise manner. Hence, we are interested in establishing whether Ward (2010) has clearly presented his results to enable any reader to pinpoint the study findings. Indeed, the researcher has used a grid to present his findings, and then conducted a detailed discussion of each literary material highlighting their findings and limitations. According to Dawes (2005), this gives a robust analysis and discussion of the findings while trying to achieve the research objectives from each perspective of the idea. Besides, the grid, together with the discussion, gives sufficient detail for the reader to extrapolate the confidence with which the results are presented. This is especially evident in the way the researcher has extracted several themes from the findings and discussed them in detail in reference to each of the reviewed studies. The researcher has also developed an internally consistent discussion which makes reference to other studies not reviewed and triangulates the data with existing theories and concepts. Downie et al (2000) insist that a properly done research study must have well-analyzed data characterised by the correct approaches to data analysis, correctly performed statistical analysis, effective analysis to ensure that significant differences are not attributable to the variations emerging from other relevant variables. Looking at the study by Ward (2010), the researcher has adopted thematic analysis, which according to Fink (2014) is an appropriate data analysis method for the literature review. Fundamentally, thematic analysis is among the most common methods of data analysis for literature review and involves an examination and evaluation of patterns (also termed as themes) within any given data (Neale, 2009). According to Guests & Namey (2015), these themes help in describing the various items related to the research question at hand. For instance, Ward (2010) has analysed his findings based three major themes namely: the role of education in the long-term or short-term improvement of compliance of safety precautions, long-term and short-term impact of education on the rates of HACI infections, and the effective methods of teaching and learning in infection control.

However, it is unfortunate that while discussing the themes emerging from each selected journal article, the author has not mentioned whether there are any significant differences in the findings of each paper that could be as a result of other relevant variables, neither has the researcher mentioned information related to the statistical analysis (e.g. p, test or test value) in the primary resources reviewed. Goaertz & Mahoney (2012) argues that when making conclusions, researchers should ensure that the concluding remarks are in line with the findings of the study because, at long last, there is a need to conclude based on the study objectives. Hence, a critique of any study cannot be complete without evaluating whether the researcher’s conclusions are based on the study findings. Looking at Ward’s (2010) study, the researcher’s main findings were that there is a difficulty in establishing the actual impact of educational intervention on compliance to safety precautions, particularly because the relationship between the two variables is mediated with several other factors such as time pressure, availability of facilities for staff use and staff risk perception – yet adjusting these factors to isolate the impact of education alone may be a difficult task. Following this, the author has concluded that there is not concrete and vigorous evidence to conclude that educational intervention is effective in improving compliance with safety precautions. This conclusion aligns to the study findings because indeed, the findings were not strong enough to conclude that educational intervention is effective.

Because the researcher did not find any concrete evidence to conclude the effects of educational intervention in improving compliance with safety precautions, he has recommended further research on the area. The recommendations have also addressed the weaknesses of the current study, i.e. the inability to isolate education as a variable from other intervening factors such as practitioner’s perception of risk.

Alemagno et al (2010) clearly and concisely state in their title that they aim to explore the effectiveness of an online continuing education program in increasing the hand hygiene knowledge and compliance among the healthcare workers. Bryman (2016) argues that a concisely stated research title must reveal to the readers what the study is trying to do, how it will do it and who it involves – so that the readers are informed of the content. However, Alemagno et al failed to mention in their tittle how the research will be carried out. Besides, little information is given about the authors, thus it is difficult to establish whether they have appropriate academic or professional qualifications to conduct such a study. This makes it hard to verify the reliability of the study findings because readers are unable to tell any contribution made by the author’s professional and academic qualification to the study (Dawes, 2005). The researchers have clearly stated the methods used to complete the study. Firstly, the study took a test and re-test design with a mixture of qualitative and quantitative methods. In doing so, the researchers tested the participant’s knowledge before and after the intervention. This design is supported by Bryman (2016), who insisted that test and re-test study designs are appropriate for educational interventions because the researchers are able to evaluate the intervention’s effects by gauging the participants’ knowledge after the intervention and comparing it with their knowledge levels at baseline. Allegranzi et al (2014) also used the same research design to successfully achieve the same objectives. Nonetheless, the knowledge evaluations at baseline and post-intervention were done through online questionnaires, and in this regard, Chalmers (2012) note that questionnaires are effective tools of knowledge evaluations because they give the participants enough time to think through and deliver the true nature of their knowledge on a particular subject. It is even better than the questionnaires were delivered online because it saved the participants time and resources (Neale, 2009).

Secondly, participants in the study by Alemagno et al were recruited from two hospitals with no specific inclusion criteria; provided they were working in a hospital facility either on full-time or part-time bases. This inclusion criterion was appropriate because the study had a general focus on healthcare workers and not on a specific department of specialty. Alemagno et al also made certain important ethical considerations that are worth noting. For instance, they assured all the respondents that their personal details would be kept confidential and because they were admitted on a voluntary basis, they were assured that their participation or lack of participation would not interfere with employment. According to Fink (2014), making such ethical considerations not only gives a peace of mind to the participants but also promotes the credibility and reliability of the study.

Results indicated that half of the participants completed the questionnaires from their home computers while half completed them from the office. This shows the remarkable convenience associated with online education programs because basically, little time and resources were spent in delivering the content unlike education programs delivered through oral presentations that consume more resources and time to complete (Chalmers, 2012). In fact, it was reported that the first session took only one hour to complete, while the second module of the program took less than one hour to complete. After analysing the change of knowledge through t-test and universal univariate change measurement, the researchers reported a significant increase in hand hygiene knowledge. For instance, at baseline, only 69.5% of participants were aware that alcohol based-hand sanitizer was among the most effective hand hygiene methods for reducing disease-causing pathogens in invisibly contaminated hands. However, after the intervention, 95.3% answered correct questions regarding alcohol-based hand sanitizers. Besides, before the intervention, only 53.5% were aware that health practitioners maintain hand hygiene less than 50% of the time. However, after the intervention, 93.4% of the respondents gave the correct answers regarding this knowledge after the intervention.

The researchers also evaluated how the participants assessed their hand hygiene practices and found a significant improvement on items direct contact with patients and their role of reminding others to maintain hand hygiene. Besides, the researchers found a significant increase in the total hand hygiene self-assessment score compared to baseline. When Alemagno et al asked their participants to select their most appropriate hand hygiene improvement practice; a majority of them selected hand sanitization before wearing gloves, hand washing before and after touching patients or equipment and reminding others to wash their hands. Last but not least, the researchers evaluated the effectiveness of the online education program and found a belief among the participant healthcare workers that the program was effective in achieving its goals. It was also indicated in the study results that the participants were impressed with the use of self-directed interventions and multi-methods that enable them to change their hand hygiene behaviour these findings are similar to the findings by Pullen (2007). These findings have several implications to practice that are worth noting. For instance, the findings imply that healthcare workers can effectively use self-assessment techniques of hand hygiene to trigger an improvement in hand hygiene compliance through an online channel. Besides, a possible implication of these findings is that a self-driven education program can create an impact on the hand hygiene knowledge and practice by creating heightened attention on hand hygiene behaviour. This is especially evident in the way participants in this study assessed and monitored their own hand hygiene compliance and made several-self-driven improvements over time. Ultimately, these findings are locally implementable because they show how self-assessment methods can be effective in improving the hand hygiene knowledge and behaviour of healthcare workers.

3.0 Change Management

Being a new thing, the proposed service user change (i.e. education intervention to improve hand hygiene compliance) is likely to encounter several challenges that require effective change management strategies. As such, Appelbaum et al (2012) propose that an intention to introduce change within the healthcare setting should be grounded on theory to enable easier visualization of the elements of change and to achieve the main objective for introducing the change. Allegranzi et al (2014) claim that compliance to hand hygiene protocols within a healthcare setting has several behavioural aspects that are culture oriented. Consequently, to effectively manage the proposed change, the implementer intends to use a culture oriented change management model that will enhance. A perfect candidate for this change management model is the HSE change model found to be logical and systematic in its ability to facilitate an effective change implementation (HSE, 2008). Similarly, the HSE model, unlike several other existing change models, focuses on the potential cultural barriers to change and provides a structured approach that highlights inclusion and communication as two factors that enable a common approach to issues and successful implementation of new ideas (Aziz, 2013).

Furthermore, the selection of the HSE change model for the proposed program is particularly informed by its ability to enable a proper understanding of the organizational culture and power systems of the proposed implementation setting, and to foresee and address issues that might potentially arise before they are prominent enough to impede the implementation stage of the change (Lucas, 2010).

3.1 Introducing the Change

As a continuing nursing student, leadership theories and project management theories studied by the implementer in earlier courses will help in gaining an effective understanding of the implementer’s role and to support the project in all the hospital departments. Besides, the implementers’ clinical knowledge on HAIs, how to prevent and control them, will also be useful in introducing the change. Ideally, this will enable the implementer to exercise their expert power as well as their legitimate and positional power as a student nurse in the hospital.

3.2 Initiation Phase

Within the HES change model are various tools that will be applied in addition to several other separate tools such as the SWOT analysis tools and Force field analysis tool, all which will be used in the implementation plan. Nonetheless, in strict adherence to the HES change model, the first phase of the program will be the initiation phase, where the implementer will develop a case for the project (HSE, 2008). In doing so, the implementer will make reference to specific existing research while evaluating the current status in comparison to the desired status of hand hygiene compliance within the implementation setting. Similarly, as an advantage of the HES change model (Young, 2009), the implementer will attempt to identify the possibility that the individuals affected by the current poor state of hand hygiene compliance are unaware that the problem exists or are unaware of the need for change, and therefore part of the activities in the initiation phase will be to make them aware of these two aspects of the situation. Furthermore, considering that the initiation phase entails preparation, the implementer will use the SWOT analysis template to identify key opportunities for success as well as the barriers to a successful implementation of the intervention. Additionally, it is within the initiation phase that the implementer will identify the project’s key influencers by conducting a stakeholder analysis.

Nonetheless, to understand the restraining and supporting forces towards the proposed intervention, the implementer will apply the force-field analysis. In doing so, the implementer expects to use their knowledge of power bases and leadership, thus identifying the key personalities within the implementation setting that they need influence in order to effectively introduce the intervention. To identify the power bases, as recommended by Avolio et al (2009), the implementer will use power taxonomy (i.e. French and Raven’s bases of power), thus being able to understand the negative and positive powers within the implementation setting that would support or derail the project. In addition, while the implementer’s favourite leadership style is transformational leadership, transactional leadership might become useful during the implementation process especially considering that conflicting interests and opinions might arise (Arvey et al, 2007). One relieving speculation is that there might be some teams that will agree from the onset to adopt and support the project by including it in their roadmap. For instance, it is expected that the hospital quality and patient safety department and the infection control and prevention team will obviously commit their support for the project. However, as part of the preparation, the implementer will also approach the hospital hygiene services committee to include them in the project, especially considering the vital role they play in maintaining the general cleanliness of the hospital. Indeed, through stakeholder analysis, early identification and inclusion of these stakeholders will assist in creating and agreeing with the case for change, as well as in the implementation process of the project (HSE, 2008).

3.3 Planning Phase

After the preparation phase, the planning phase will follow. According to HSE (2008), implementers should seize the opportunity of this phase to develop a roadmap that outlines the timely action plans that build up to the achievement of final project goal. Hence, in the current project, the implementer will use the planning phase to develop bits of the intervention and action plans that will ultimately contribute to improved compliance to hand hygiene behaviours. According to HSE (2008), the preparation activities that were carried out in the initial stages will be of great benefit in regards to getting the plan to be fully embraced and getting the stakeholders on board for purposes of timely execution of the project.

3.4 Implementation Phase

Despite having developed the implementation plan in the second phase, it is expected that the actual implementation of the project (i.e. the third phase) will not be smooth or straightforward. According to HSE (2008), the phase is more time consuming especially considering the fact that the actions involved in this stage require consistent follow-ups. Besides, Barrow et al (2008) explain that the troublesome nature of this phase is contributed by the fact that it involves constant negotiations with both internal and external stakeholders. Thus, according to Brazil et al (2010), the implementer’s role in this phase will be to offer primary coordination and leadership of the various elements of the implementation phase.

3.5 Mainstreaming

The fourth and final phase of the model is mainstreaming, which according to Caldwell et al (2009) entails sustaining the change into new ways of behaving and working within the implementation setting, and apparently may be the most challenging part. Besides, Cellars (2007) notes that this phase entails project measuring and evaluation to identify its impact. As such, the implementer will use the Kirkpatrick Model (I.e. Kirkpatrick, 1994) as the measuring and evaluation strategy. However, Carlstrom & Ekman (2012) warns that the implementer should be prepared to receive any kind of feedback (i.e. negative or positive) considering the time and resources employed in the entire project and the expectations surrounding it. Moreover, Caldwell et al (2009) advise that as a leader, the implementer should not express hunger and frustrations in the presence of the team.

4.0 Conclusion

During the literature review, it came out clearly that hand hygiene compliance is associated with barriers and successful actions. For instance, it has emerged that it may be difficult to identify the specific impacts of hand hygiene educational intervention among health workers, considering that knowledge acquisition is influenced by many factors including availability of adequate teaching resources, availability of time and participants’ perception of risk. Nonetheless, we recommend that change implementers should develop research skills that enable develop service improvement through the introduction of innovative change. In doing so, they should consider learning the processes of literature search and analysis by familiarising with available literature critique tools such as the Critical Appraisal Skills framework (CASP) and the Cormack’s framework. In the spirit of nursing practice, nursing students’ curriculums should also include courses that enhance the leadership and change management capabilities of nursing students. Finally, we recommend that further research should be conducted to develop concrete and vigorous evidence establishing the effectiveness of the educational intervention in improving compliance with safety precautions especially in the field of hand hygiene.

References

Alemagno SA et al. (2010) ‘Online Learning to Improve Hand Hygiene Knowledge and Compliance Among HealthCare Workers’, Journal of Continuing Education in Nursing, 41(10), pp. 463–471.

Allegranzi, B., Conway, L., Larson, E. and Pittet, D. (2014) ‘Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities” American Journal of Infection Control 42(3), pp. 224–230

Appelbaum, S., Habashy, S., Malo, J. and Shafiq, H. (2012) ‘Back to the future: Revisiting Kotter's 1996 change model’. Journal of Management Development, 31(8), pp. 764 – 782

Avolio, B. J., Walumbwa, F. O. and Weber, T. J. (2009) ‘Leadership: Current Theories, Research, and Future Directions’. The Annual Review of Psychology, 60, pp. 421-449

Barrow, B., Mehler, P. and Price, C. (2008) ‘A communications campaign to designed to improve hand hygiene compliance and reduce infection rates.’ Journal of Communication in Healthcare, 2(1), pp. 61-77

Brazil, K., Wakefield, D. B., Cloutier, M. M., Tennen, H. and Hall, C. (2010) ‘ Organisational culture predicts job satisfaction and perceived clinical effectiveness in paediatric primary care practices’. Healthcare Management Review, 35(4), pp. 365-371

Caldwell, S.D., Roby-Williams, C., Rush, K. and Rickie- Kiely, T. (2009) ‘ Influences of context, process and individual differences on Nurses’ readiness for change to Magnet status’. Journal of Advanced Nursing, 65(7), pp.1412-1422.

Carlstrom, E.D. and Ekman, I. (2012) ‘Organisational culture and change: implementing Personcentred care’. Journal of Health Organisation and Management, 26(2), pp. 175-191.

Chau, J.P.C., Thompson, D.R., Twinn, S., Lee, D.T.F. & Pang, S.W.M. (2011) An evaluation of hospital hand hygiene practice and glove use in Hong Kong. Journal of Clinical Nursing 20 (9-10); 1319-1328.

Cohen ML (1992) Epidemiology of drug resistance: implications for a post-antimicrobial era. Science. Aug 21; 257(5073):1050-5

De Brún, C. and Pearce-Smith, N. (2009) Searching Skills Toolkit; Finding the Evidence. BMJI Books: London

Downie, R.S., MacNaughton, J. and Randall, F. (2000). Clinical Judgment: Evidence in Practice. Open University Press.

Fuller, C., Savage, J., Besser, S., Hayward, A., Cookson, B, Cooper, B. & Stone, S. (2011) The dirty hand in the latex glove: a study of hand hygiene compliance when gloves are worn. Infection Control & Hospital Epidemiology 32 (12); 1194-1199

Flaherty P. Weinstein R. (1996) Nosocomial infection caused by antibiotic-resistant organisms in the intensive-care unit , Infect Control Hosp Epidemiol. Apr; 17(4):236-48.

Girou, E., Chai, S.H.T., Oppein, F., Legrand, P., Ducellor, D., Cizeau, F. & Brun- Buisson, C. (2004) Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission? Journal of Hospital Infection 57 (2); 162-169

Health Protection Agency (2012) English National Point Prevalence Survey on Healthcare-associated Infections and Antimicrobial Use 2011 London: Health Protection Agency

Neale J (ed.). (2009). Research methods for health and social care. Basingstoke: Macmillans. Good basic research book.

National Audit Office (2009) Reducing Healthcare Associated Infections in Hospitals in England. London: The stationery Office

Pullen, D. (2007). An evaluative case study of online learning for healthcare professionals. Online Continuing Education, 37(5), 225-232.

The Review on Antimicrobial Resistance (2014) (launch paper), Lord Jim O’Neill, December 2014, p4