Evidence Based Nursing Research on Hand Hygiene Compliance and Hospital Acquired Infections

This research paper focuses on the significance of hand hygiene compliance in reducing the spread of hospital acquired infections. It includes a PICO table, keywords, and a systematic review of research and non-research evidence. The paper recommends practice changes and identifies stakeholders for implementation.

Running head: NURSING
Evidence Based Nursing Research
Name of student:
Name of university:
Author note:
a.

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A.1 Healthcare Problem
Research indicates that one of the most important contributory factors towards hospital
acquired infections (HAI) is hand hygiene compliance among professionals from the healthcare
field. Non-compliance to guidelines for hand hygiene techniques leads to rapid increase in the
prevalence of HAI among healthcare setting patients. Even though it is known that hand hygiene
is essential element of standardized care practices, in consistency is highly evident from the
unsatisfactory national average rate of compliance.
A.2 Significance of the Problem
As opined by Watson (2016), a leading cause of high mortality rate of hospital admitted patients
is transmission of infectious diseases in such settings. The infection is such cases originates
primarily from the environment around the patient including an infected patient, an infected staff
and an infected visitor. The issue of infectious disease can be prevented or reduced if
professionals adhere to hand hygiene practices since the most frequent and important mode of
transmission of infections is by direct contact (Cure, 2015). Controlling hospital acquired
infection refers to implementation of quality control or quality assurance measures within the
respective settings along with evidence-based management measures which can be considered as
significant and feasible approach. In my opinion, the issue has implications for the healthcare
workers, as well as the public. Healthcare professionals have the accountability for being the
advocate of patients. However, it is the responsibility of the patient, the family members and also
the visitors to understand the importance of hand hygiene practice (Srigley, 2016). As per the
information provided in CDC website, a study carried out in 2015 indicated that about 20 percent
of all hospitalized patients get infected with any contagious disease at the time of hospital stay,
including pneumonia, blood stream infections, urinary tract infections, surgical site infection.

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The cost of educating all stakeholders about hand hygiene problem would be less than that of
treating patients acquiring HAI. Hand hygiene is therefore a significant problem owing to spread
of HAI, and needs further investigations.
A.3 Current Practice
As highlighted by Cure (2015) most of the health care settings consider educating about
the importance of hand hygiene prior to and after coming in contact with the patients. In the
United States, hand hygiene protocol mainly involves use of hand sanitization foam or canisters
placed at the door of the respective rooms. In the majority of the settings, instructions are given
to cover body surfaces with sanitizing foam that includes their wrists, hands, fingers and spaces
between them. Instructions are further given to use water and antibacterial soap for scrubbing
body areas and use paper towel for turning off the water tap for ensuring that the cleaned hands
are not further contaminated (Neo, 2016). The rate of hand hygiene is about 11 to 60%.
Nevertheless, those above 50% are not common (Salmon, 2015). In a number of under
developed countries, the percentage is still lower as a result of lack of provision of clear water,
restricted resources, poor knowledge and education about hand hygiene compliance (Salmon,
McLaws, 2015). It has come to my notice in the facility where I work that the responsibility of
hand hygiene protocol compliance is highly neglected. In spite of regular communication being
made regarding the need of adhering to such practices, discrepancies remain in applying the
same.
A.4 Impact on Background

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Undertaking research has expanded personal knowledge regarding the implications of
hand hygiene practice as lack of compliance is a notable cause of rapid spread of infectious
diseases across the care continuum. The particular population who are mostly effected by the non
adherence of professionals to hand hygiene practices is the patient population admitted to
nursing home facilities of hospital settings. It is however to be remembered that a number of
factors influence the adherence to the practices that in turn is responsible for influencing the
extent of spread of infection. Nevertheless, hand hygiene has been a cost-effective way of
decreasing the prevalence of HAI (Rodriguez, 2015). The different modalities that can ensure
proper compliance with hand hygiene protocols include regular and accurate education
impartment, availability of hand sanitization sinks and stations, and other (Watson, 2016). As per
the researchers, there is a rich pool of research to support the direct link between hand hygiene
compliance and significant reduction in prevalence of HAI. However, in spite of education, a
number of underdeveloped countries are not able to completely adhere to the practices as a result
of limited resources (Salmon, McLaws 2015).
B.1 PICO Table
P(patient/problem) Spread of infectious diseases in healthcare settings
I(intervention/indicator) Hand Hygiene Compliance with outlined procedure
C(comparison) No hand hygiene Compliance with outlined procedure
O(outcome) Decreased spread of infectious diseases
B.2 PICO Question

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Does proper hand hygiene procedure compliance lead to decreased spread of infectious
diseases as compared to improper hand hygiene procedure compliance?
C.1 Keywords
Hand Hygiene, Infectious diseases, compliance, Procedure.
C.2 Number and Types of Articles
For carrying out the research in a reliable and valuable manner, it was crucial to have a
systematic approach in selection of articles. It is pivotal that one screens the articles based on
their reliability and credibility. The Western Governor’s library was used for the research on the
selected PICO question. The initial research on hand hygiene solely yielded about 94,981 articles
published between the years 2014 and 2018. The research was further narrowed down by adding
the keyword compliance after which the number of retrieved articles was reduced to 26,315. A
further refinement was considered by adding the keyword infectious disease, and the number was
down at 9,031. The Peer Reviewed option was then selected for further decreasing the number of
articles to 4,910. Selection of clinical trials yielded total number of 4,778 articles. Out of the total
articles, two were cross-sectional or cross-over studies, one was literature review, one was wedge
trial, two were quasi-experimental pre – post intervention studies, one was survey article and one
was focus group survey. In my opinion, the most reliable evidence came from those studies
where primary data collection was done with measurable outcomes studied in relation to
compliance.
C.2a Research and Non-Research Evidence
The first research article considered for the present review was authored by Watson, J. A.
(2016) with the title ‘Role of a multimodal strategy on health care workers’ hand washing’. The
aim of the study was to analyze how hand hygiene compliance can lead to increase as a result of

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educational strategies that are multimodal in nature by utilizing the World Health Organizations
My 5 Moments for Hand Hygiene. Data collection setting was a level II trauma center with the
study population of healthcare workers having direct contact with patients. Three different units
were included in the study including a pulmonary unit, Intensive Care Unit, and a medical –
surgical floor. Educational materials were developed on the basis of existing literature and
approval from the World Health Organization was taken. A quasi – experimental research design
considered a survey data collection tool through which opinions of healthcare workers were
taken related to multimodal intervention education. The survey tool considered questions related
to pre-awareness state and post-awareness state. It was determined that compliance to hand
hygiene was increased significantly from 51.3% to 98.6% after the completion of three month
trial period. It was further understood in this relation that the healthcare workers showed
increased interest to adhere to the hand hygiene practice after awareness level increased through
multimodal interventions on hand hygiene.
The second research that was reviewed had been authored by Salmon and McLaws
(2015) and had the title as “Qualitative findings from focus group discussions on hand hygiene
compliance among health care workers in Vietnam”. The research had the focus on global
significance of compliance with hand hygiene protocol for prevention of spread of infections that
this leads to apprehension in countries having limited resources. It was stated that though
research points out the benefit of multimodal interventions, difficulties are immense in
maintaining them. These are more prominent in areas where resources are restricted,
overcrowding of care settings is evident and accurate data on HAIs is limited. The qualitative
study with 12 focus groups considered physicians and nurses working at six different healthcare
settings each having distinct policies regarding hand hygiene protocol. Analysis of results

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pointed out that knowledge of professionals regarding hand hygiene is not adequate in areas
where limitation of resources is a key concern. Inadequate knowledge is not sufficient enough to
address subjective bias in relation to self-preservation due to lack of simplified educational
materials. The article also pointed out that professionals are to be given more education on
infection transmission which can reflect level of understanding and availability of resources to
them.
The first non-research article that had been selected was “Interventions to improve patient
hand hygiene: a systematic review” by Sringley (2016). In this study the focus of the researcher
was to study the significance of compliance with the hand hygiene protocol as implied to
healthcare workers as well as the public and patient. The article indicated that there is a tendency
to overlook the importance of compliance from the patient’s end though non compliance leads to
spread of infections at the time of admission. It was stated that hand sanitizer dispensers placed
in an inconvenient manner leads to non compliance to a considerable extent. It is therefore
suggested that since immobility of patient is a major concern, it would be beneficial to increase
the provision for sanitizers at bedside and table top which are portable. Another beneficial
approach to prevent transmission of infectious diseases within the setting is education. The
review highlighted that evidence-based research is to be undertaken for increasing awareness
level of patients as well as that of the public regarding significance of hand hygiene.
The second non-research paper considered for the study was titled as “Hand hygiene-
related clinical trials reported since 2010: a systematic review” authored by Kingston (2016).
The study focused on different trials conducted on hand hygiene compliance and the relation
with infection transmission. It was pointed out by the authors that though hand hygiene
compliance has been noted as a concern on the international basis, studies reviewing the matter

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are limited, and most of the existing ones have been carried out in the United States or Europe. It
was also noted that the studies that have been carried out considered critical care units such as
the ER, ICU and step-down units. The article further pointed out the scarcity of research
associated with the appropriate technique for hand hygiene. Further, the researchers stated that
multimodal education for hand hygiene is the best approach for increasing compliance level.
Nevertheless, future research in this direction must consider healthcare students who are the
future professionals.
E. Recommended Practice Change
The evidence gathered through the present research is in support of the requirement of
future education efforts in relation to the suitable hand hygiene practices for prevention of spread
of infections. The articles that were under scrutiny showed that convenient locations for hand
sanitizing stations with adequate water and soap, and alcohol can improve hand hygiene
compliance. The lack of suitable protocol implementation and insufficient education regarding
hand hygiene are concerns on the global scale.
For increasing compliance and reducing spread of infectious agents it is recommended
that My 5 Moments for Hand Hygiene from the World Health Organization reminder posters are
to be placed at each sanitizing station and in patient rooms (Patel, 2016). Further, hand hygiene
stations are also to be made more visible so that access sis made easier in cafeteria, lobbies halls,
and break rooms (Cure, 2015). It is further recommended that alcohol dispensers are placed at
convenient locations in patients’ rooms (Kirk et al., 2016).
Finally there would be a need of increasing education imparted on hand hygiene
compliance for prevention of spread of diseases and adapting to the learning abilities of the
target audience with the help of the guidelines provided by WHO (Salmon, 2015). I also aim at

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increasing the time needed for engagement in learning about the different strategies for
compliance to hand hygiene techniques. Training and teaching healthcare workers as well as
patients for increasing knowledge would also be pivotal (Rodriguez, 2015).
F. 1 Stakeholders
Three individuals whom I would select for being stakeholders in implementation of the
ideas are health care workers, administration and facility education staffs. The healthcare
workers are the employees having direct and indirect contact with patients. They are considered
as the chief reason for infection transmission in absence of hand hygiene compliance. The
professionals would need to take the responsibility of engaging in continual research and
implementing interventions aligned with the purpose of hand hygiene compliance. Moving
further, the education team would form the second stakeholder in this regard. This group is
responsible for educating the employees of care setting. In addition, they need to deign
appropriate programs that can impart adequate education to the target audience. It is also their
responsibility to ensure that all employees are included in the program. Meetings are to be
conducted by the team on a regular basis at least once in a month for adjusting the agendas of the
education programs. Lastly, the facility administration are to be considered as a stakeholder
group wherein they would have a proactive approach in increasing compliance with the hand
hygiene protocol. The key responsibility of this group would be to approve practice changes
outlined so that assistance can be provided for successful implementation of the changes related
to the educational processes. They are also to take part in regular monitoring of improvement of
the process. The aim of such monitoring would be to understand whether compliance with
practices on healthcare worker’s part is evident as a result of understanding decrease in the

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spread of infection. Another responsibility of the administrators would be to approve funds for
the education programs and improvement in availability of hand hygiene stations.
F. 2 Barriers
A significant barrier to adequate hand hygiene in my healthcare facility would be time
constraint. Like many health care facilities, there is a lack of nursing staff for delivering optimal
care to the patients. The shortage in staff compels the professionals to take shortcuts in practice
which are not desirable. This includes usage of sanitization station at the time of leaving the
patient’s room but not conferring to the same practice at the time of entering the room. The
justification that they provide is that they need to use the sanitization station while attending the
patient in the next room. This not only indicates poor practice on the professional’s part but also
lack of adequate education regarding the significance of complying to the guideline
appropriately. A second barrier that can emerge in the facility is inconvenience faced by
professionals due to poor placement of alcohol dispensers and sinks I work in the ER which has
provision for sink at each room as one enters the room. Nevertheless, most hospitals have the
sinks placed away from the door, making it inconvenient to access them. But it can also be
argued that alcohol foam dispensers are placed in all rooms, both on the floor and in the ER.
Nevertheless, the location of such dispensers is not always convenient as they are placed on the
opposite side of the door from the entry point.
F.3 Strategies for Barriers
Inadequate staffing is a key concern and needs to the addressed as the first priority. This
issue can be resolved if more healthcare workers are recruited. In this regard it is also to be
mentioned that adequate training needs to be given to the newly recruited professionals so that
they can become more skilled and competent within a short span of time. However, if

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recruitment of professionals is not possible, it can be compensated by increasing education on
hand hygiene compliance. The agenda would be to increase education level of the existing staff
so that transmission of infectious diseases is possible. The barrier can be overcome if one
considers addressing the barrier of proper placement of foam dispensers and sinks. Though there
is a possibility that number of soap dispensers and sinks would be limited as a result of pipe
placement and plumbing, the alcohol foam dispensers are portable and can be used accordingly.
When the number of dispensers is increased, there would be easy access to the same. In addition,
they would be more visible to all stakeholders including the patients and the visitors. In my
opinion increased education that leads to increased awareness, and increase in convenience of
use of alcohol dispensers would be strategic steps for addressing the barriers mentioned.
F.4 Indicator to Measure Outcome
There exist multiple strategies through which my recommended change in practice can be
considered for measurement. Measurement leads to understanding of needs of future
improvement. The simplest manner in which changes can be measured is to undertake
monitoring of monthly costs related to alcohol-based foam hand sanitizers. Monitoring refers to
the regular and systematic collection of information and subsequent analysis for tracking the
progress of subject under scrutiny. This is done against pre set objectives and targets. It is
important to clarify the objectives, link the activities to objectives, set targets and routinely
collect data. After one figures out the cost increase at initial stage related to new dispensers and
the cost for current dispensers, the success of implementing the change can be understood. This
is ideally to be measured consistently for minimum of three months. After that, quarterly reviews
can be considered that would indicate if the dispensers are being used in an appropriate manner.

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A different measurable outcome for monitoring would be a decrease in the rate of hospital or
facility acquired infectious diseases. It is to be expected that impartment of education to the
target audience along with increase in the number and accessibility of hand hygiene station
would lead to decline in the number of infections in a steady manner. It is also an established
practice to keep a track of HAI in most of the care facilities since the economic burden of the
diseases is high. Thus it can be stated that monitoring would not bring in much challenges in due
course of its process. In addition, though further efforts might be required for recruiting
additional staff, measurable outcomes would be possible as a result of observations in relation to
education imparted. This might be challenging for measurement and implementation as human
resource would be needed for monitoring staff as compliance rate is to be monitored accurately.
A key idea would be to monitor once a month for an hour. The compliance rate would be
compared to the number of opportunities and record is to be maintained every quarter for
understanding improvement regarding compliance.