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Section 1: Nature of the Project
Introduction
Patients enter an inpatient acute care setting for medical treatment or
management. Regardless of the reason for entering the hospital, the healthcare team takes
on the task of caring for the patient and the responsibility to provide safe patient care,
promote healing, and cause no harm. Goals are set for patients on admission, which are
evaluated daily to better understand how the patient is progressing, and team members
from multiple disciplines work together to meet those goals before discharging the
patient. The important goals of inpatient hospitalization are to promote wellness, improve
health and healing, provide a safe healing environment, and secure improved patient
outcomes.
A safe healing environment is a crucial part of an inpatient acute care setting. It
allows for patient progression towards positive health outcomes and return to daily
activities and life functions. Healthcare staff play a vital role in positive patient outcomes
and the prevention of complications, such as healthcare-associated infections (HAIs). An
essential component of preparing to work in a clinical setting as a healthcare provider is
the understanding of the infection process and techniques to prevent it (Olin, 2012).
According to Lavigne & Curran (2015), many times healthcare staff lack the knowledge
of appropriate technique or basic training of proper hand-hygiene protocols to ensure
adequate compliance. The World Health Organization’s (WHO; 2009) “Clean Care is
Safe Care” program has offered various strategies to improve hand hygiene. They are
(a) ensuring that healthcare staff has access to alcohol-based hand rub in the patient care
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setting, (b) education and training of healthcare staff on the importance of hand hygiene
compliance, (c) monitoring and feedback on hand hygiene compliance, (d) visual
reminders of compliance in the patient care setting, and (e) creation of a culture of
attention to safety within the organization (WHO, 2009). The WHO is leading a global
effort to improve hand hygiene compliance, with over 170 nations signed up for the
“Clean Care is Safe Care” campaign (Graves et al., 2016).
A magnet-designated hospital in the Southeast uses the WHO’s “My 5 Moments
for Hand Hygiene” guideline as its adopted hand hygiene tool. The hospital is an 82-bed
facility serving the local community. This project focused on reeducating
healthcare staff
working on the medical-surgical unit and the intensive care unit of the hospital on hand
hygiene guidelines.
HAIs are a global healthcare challenge. To be considered healthcare-acquired,
infections must be contracted by patients up to 48 hours after hospital admission, up to 3
days after discharge, or up to 30 days after an operation (Stubblefield, 2016). HAIs are
one of the most serious patient safety issues in healthcare globally. According to the
Centers for Disease Control and Prevention (CDC; 2017a), in 2014 there were an
estimated 722,000 HAIs in U.S. acute care hospitals, and about 75,000 patients with
HAIs died during their hospitalization, which is approximately 205 deaths from HAIs
every day. Because HAIs are not always the underlying cause but rather a contributing
cause, HAI-related death rates are difficult to track. According to the CDC (2001), the
impact of HAIs can also be examined in terms of years of life that were lost. The median
age for patients dying with HAIs is 57 years (CDC, 2001). The results of a study done
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between July, 2008, and September, 2011, in a children’s hospital by Song, Stockwell,
Floyd, Short, and Singh (2013) showed that when healthcare staff were reeducated on
hand hygiene practices, compliance increased from 50.3% pre education to 84.0% post
education, resulting in savings of $66,397 in hospital charges per month and 11.6 hospital
days (Song et al., 2013). Research shows that if health care organizations, doctors,
nurses, and other care team members are aware of infection problems and follow specific
steps and protocols to prevent them, HAI rates can decrease by more than 70% (CDC,
2017a). According to Aziz (2014), despite the awareness that HAIs cause substantial
preventable morbidity and mortality, healthcare staff have a strong tendency to view
HAIs as far less of a threat to patient safety than other adverse events such as falls or
medication administration errors.
The purpose of this project was to reeducate healthcare staff on the importance of
hand hygiene compliance in the prevention of HAIs in an acute care setting. The potential
positive social change implications of this project are decreased HAIs resulting in better
patient outcomes, eased financial burden on society, decreased healthcare costs, and
improved quality care achieved through better hand hygiene compliance among
healthcare staff on the two units.
Background
In 2009, The World Health Organization developed evidence-based guidelines on
hand hygiene in a healthcare setting to support hand hygiene improvements and thus
reduce HAIs (WHO, 2018). The “My 5 Moments of Hand Hygiene” are before patient
contact, before an aseptic task, after body fluid exposure risk, after patient contact, and
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after contact with patient surroundings. The Southeast hospital adopted in 2010 the
WHO’s “My 5 Moments of Hand Hygiene” guideline as to when hand hygiene should be
performed. These guidelines are taught during hospital orientation, and healthcare staff
also must complete a yearly computer-based training program as well as yearly
performance hand hygiene check-offs. According to Power & Cole (2017), educators
need to be increasingly compelled to consider innovative approaches to teaching and
learning strategies because the more traditional forms of skill teaching do not foster
essential critical decision-making skills. The more learners are encouraged to incorporate
their understanding and knowledge of the underlying evidence base, the better the
learning goal outcome will be (Power & Cole, 2017). Shapiro (2018) identified four tips
for better learning: (a) encoding, which involves converting perception into meaningful
representations; (b) consolidations, which is giving meaning and filling in missing
information; (c) retrieval, which is associating memories with diverse cues that allow
recall; and (d) effort, which involves a deeper and more enduring learning. Healthcare
staff need to fully understand the evidence-based background of the “My 5 Moments of
Hand Hygiene” guideline development and statistics to fully understand why compliance
is so vital in a healthcare setting.
Problem Statement
The infection preventionist at the Southeast hospital identified a need for
reeducation of healthcare staff on specifics of the hand hygiene protocol. Based on daily
audits done on the two units, hand hygiene compliance has been as low as 59% in the
past 1 month indicating a need in hand hygiene reeducation. The problem being
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addressed in the project was hand hygiene compliance in an acute care setting. The goal
of the project was to provide hand hygiene reeducation to healthcare staff following the
implemented guideline to prevent HAIs.
HAIs remain a major problem that healthcare organizations face daily. Their
development can lead to higher mortality and morbidity rates, increased length of
hospital stays, and a financial burden for both patients and hospitals. The financial
repercussions of HAIs are high. According to the CDC (2017a), the estimated annual
direct hospital cost for treating hospital-acquired infections ranges from $28.4 billion to
$33.8 billion. Microorganisms present on surfaces and equipment around patients or
carried by healthcare staff are a source of HAIs (Helder et al., 2014). Therefore,
promoting hand hygiene compliance needs to remain an ongoing effort. Proper hand
hygiene is one of the most significant measures for the prevention and control of
microbial pathogen cross-transmission and for many infectious diseases a cost-effective
intervention (Ford, Boyer, Menachemi, & Huerta, 2014). Preventing HAIs is possible but
requires a conscious effort to work toward protecting patients, improving patient care,
and saving lives. One way to reduce HAI rates is to further educate healthcare staff on
hand hygiene protocols.
Purpose Statement
The purpose of this staff education project was to educate healthcare staff on hand
hygiene to prevent HAIs in an acute care setting and to provide recommendations
regarding the sustainability of the reeducation initiative after the completion of the
project.
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The meaningful gap in nursing practice that this educational doctoral project
addressed is hand hygiene compliance among healthcare staff in an acute care setting.
The guiding practice focus question for this project was:
PFQ: Will reeducating healthcare staff regarding the importance and significance
of hand hygiene help improve hand hygiene compliance rates in an acute care
setting?
The gap in practice is addressed through reeducation and the findings are disclosed in
proposed measures. Through this project, I developed
educational strategies.
Hand hygiene compliance needs continuing education (Kapil, Bhavsar, & Madan,
2015). The display of posters acts as an effective educational tool (Kapil et al., 2015). It
is one way to emphasize basic hand washing standards, including when the procedure
should be performed, what products to use, description of proper techniques, and
appropriate duration of procedure (Szilagyi et al., 2013).
The WHO recommends a multimodal hand hygiene strategy. Successful and
sustained hand hygiene improvement is achieved by the implementation of multiple
actions to address different obstacles and behavior barriers. I developed hand hygiene
educational posters reflecting the latest evidence-based practices and standard protocols
using the World Health Organization’s “My 5 Moments of Hand Hygiene.” (WHO,
2012). Participants were educated on the content of the educational materials: the
importance of hand hygiene compliance and its relevance to the prevention of HAIs.
Scenario-based education was also used as part of the multimodal approach. Long used in
medical education, patient case studies provide examples to learn from. Scenario-based
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experience allows healthcare staff to care for virtual patients, make real-time care
decisions, and receive immediate feedback through natural consequences. During the
educational sessions, a power point presentation was used on the “My 5 Moments of
Hand Hygiene.” The infection preventionist also attended some of the educational
sessions and was involved in sharing hand hygiene facts, statistics, and learning content
with staff.
Hand hygiene reeducation is an important aspect of HAI prevention. HAIs are a
major health burden and represent a global safety concern (Tartari et al., 2016). It is an
epidemic that will continue to be on the rise if changes in hand hygiene compliance are
not made. If no changes are made, the best predictor of future incidences remains the
past. The CDC is in charge of tracking HAIs, and the data from the years 2014 to 2015 is
disappointing. Of the six different HAIs being monitored and tracked, only one infection
rate showed a decrease, two infection rates showed no change, while three infection rates
increased: catheter-associated urinary tract infections rates showed a 43.0 % decrease,
central line-associated bloodstream infection showed a 21.8% increase, surgical site
infection-abdominal hysterectomy showed no significant change, surgical site infection-
colon surgery showed a 3.3% increase, methicillin-resistant Staphylococcus aureus
bacteremia showed a 9.9% increase, and clostridium difficile infection showed no
significant change (CDC, 2017c). Based on the WHO (2017) estimate, the annual
financial losses due to HAIs are significant. The estimated loss in Europe is 7 billion
euros, reflecting 16 million extra days of hospital stay, and approximately $6.5 billion in
the United States, reflecting 14 million extra days of hospital stay. Financial
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consequences will continue to increase with increased infection rates. It is critical that
healthcare staff in the acute care setting are educated on hand hygiene protocols and
comply with those protocols to prevent HAIs.
Project Objectives
At the end of the project the following objectives were expected to be achieved:
• To reeducate healthcare staff regarding the importance and significance of
hand hygiene practices and compliance to reduce HAIs.
• To compare hand hygiene compliance rates 1 month before and 1 month after
the reeducation of healthcare staff regarding hygiene practices.
• To provide recommendations regarding the sustainability of the reeducation
initiatives following the completion of the project.
Nature of the Doctoral Project
The sources of evidence collected to meet the purpose of this doctoral project
included peer-reviewed scholarly journals, organizational protocols, and evidence-based
guidelines gathered from reliable sources, which came mainly from the Walden
University Library. I used electronic databases such as CINAHL, Medline, PubMed, and
ScienceDirect with key terms such as “healthcare-acquired infections,” and “hand
hygiene” to find evidence-based data and information related to the project. The approach
that was used to organize the evidence was grouping data by the dependent variable, the
indicator of success, which was an increase in hand hygiene compliance, following
healthcare provider reeducation on hand hygiene. The approach to analyzing the evidence
was the examination of data for relationships, patterns, and trends that could be found in
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the evidence collected. The analysis focused on whether there was a significant change in
the variable that I was attempting to influence, in this case an increase in hand hygiene
compliance rates. The purpose of this doctoral project was to connect the gap in nursing
practice through healthcare provider education on hand hygiene compliance to prevent
HAIs in an acute care setting.
Significance to Social Change in Practice
Healthcare workers’ compliance with hand hygiene is critical in the prevention of
HAIs in patient care settings (Vandijck, Labeau, Vogelaers, & Blot, 2010). Key
stakeholders in this doctoral project included patients who stand to benefit from a
decrease in HAI rates, and healthcare staff who through further hand hygiene education
provide higher quality patient care. In addition, the organization stands to benefit
financially through reimbursements, decreased costs, increased patient satisfaction, and
better patient outcomes.
The goal of this doctoral project was to influence social change by heightening
the importance of hand hygiene compliance for healthcare staff to prevent HAIs among
patients in an acute care setting. Reeducation is based on the theory of behavioral change
at the individual, interpersonal, and organizational levels. At the individual level, hand
hygiene reeducation reinforces the right motivation and need for hand hygiene
compliance. At the interpersonal level, reeducation of healthcare staff empowers them to
improve patient outcomes through the prevention of HAIs. At the organizational level,
reeducation includes a shift in the way healthcare staff think about hand hygiene,
restructures the organization, and develops appropriate philosophies that support hand
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hygiene compliance to prevent HAIs. Increase in hand hygiene compliance is a topic to
be addressed in all healthcare settings including doctor’s offices, outpatient care, home
health, and other areas where patient care is provided. It is an important aspect of quality
nursing practice.
Summary
The introduction section of this evidence-based staff education project presents an
overview of the need for healthcare provider reeducation on hand hygiene in an acute
care setting to help prevent HAIs. HAIs can contribute to negative patient outcomes and
higher healthcare costs. According to the CDC (2017), HAIs are a worldwide threat to
patients.
Section 2 further details reviewed scholarly evidence on hand hygiene in the
effort to prevent HAIs. In this section, I examine the impact of hand hygiene compliance
on the prevention of HAIs in further detail.
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Section 2: Background and Context
Introduction
The primary goal of this DNP project was staff education. The practice problem
was low hand hygiene compliance in an acute care setting. The goal of the project was to
provide hand hygiene reeducation to healthcare staff, following the implemented WHO’s
“My 5 Moments of Hand Hygiene” to prevent HAIs. According to Maroldi et al. (2017),
no health service in any country can be considered HAI risk free. Improving health care
worker’s hand washing practices remains the most effective method to prevent HAIs in a
hospital setting. The guided practice focus question for the project was:
PFQ: Will additional education on hand hygiene help healthcare staff better
understand HAI prevention and increase hand hygiene compliance?
In Section 2 of the DNP project I examine scholarly literature
regarding hand
hygiene and HAIs, concepts and theories, the project relevance to nursing practice, local
background, my role as the DNP student, and the role of the project team.
Concepts, Models, and Theories
The evidence-based practice model, Florence Nightingale’s environmental theory,
is the model that was used for this project. It is a theory that changed the face of nursing
practice (Petiprin, 2016). Nightingale was one of the first nurses to address the impact of
environment on patients (Zborowsky, 2014). She addressed topics such as sanitation,
infection rates, ventilation, and how the nurse’s presence contributes to patient health
outcomes (Zborowsky, 2014). Her environmental theory is a systems model that is
focused on the patient. Nightingale stressed physical environment as a very important
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contributor to patients’ well-being. To promote healing, she emphasized that healthcare
staff should maintain a clean and safe healthcare environment (Zborowsky, 2014). Proper
hand hygiene is the most important aspect in the reduction of HAIs and was one of
Florence Nightingale’s main aspects.
The environmental theory could be used specifically for this project by helping
participating healthcare staff understand how critical a clean environment is in promoting
the healing process. My intentions for the educational project were that patients would
remain infection free and could be discharged to continue with their lives. By using the
environmental theory, healthcare staff could better understand the goals of the
educational project. I used a quantitative analytic method to complete this project: to
investigate healthcare staff understanding of and educate staff concerning the connection
between hand hygiene compliance and HAIs.
Relevance to Nursing Practice
The main goal of healthcare is to treat, cure, and prevent diseases. Nurses are at
the frontline of healthcare and are expected to be diligent in ensuring that patients receive
the best possible care with the best possible outcome, allowing for patients to overcome
their health challenges (Brownson, Baker, Leet, Gillespie, & True, 2011). The WHO
(2009) has acknowledged the importance of hand hygiene in the prevention of HAIs. One
example is the “Five Situations” when healthcare staff need to perform hand hygiene: (a)
before having any contact with patients, (b) before performing an antiseptic task, (c) after
exposure to bodily fluids, (d) after contact with a patient, and (e) after having contact
with a patient’s surroundings (WHO, 2010). According to the CDC (2017),
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approximately 75,000 lives are lost each year due to HAI complications during
hospitalization, lives that could be saved if organizations, doctors, healthcare staff, and
other healthcare team members followed specific steps and protocols to prevent HAIs.
Hand hygiene protocol compliance is as low as 50%; the need to do better is revealed in
the numbers (Helder et al., 2014). The gap in nursing practice is the need for nursing and
other healthcare provider reeducation on hand hygiene to prevent HAIs in an acute care
setting by increasing hand hygiene compliance. Organizations have hand hygiene
protocols in place to prevent HAIs, but with compliance rates as low as 50% among
healthcare staff, there is a great need for improvement. Reeducation of healthcare staff
equips them with further knowledge on the importance of hand-hygiene compliance and
its benefits in the prevention of HAIs, which leads to better patient outcomes.
Local Background and Context
Evidence shows that the spread of HAIs in the hospital environment is directly
connected to health care professionals who provide care to patients (Ramos de Oliveira
Douardo, Barros, Vasconcelos, & da Silva Santos, 2017). The effectiveness of hand
hygiene use before patient contact in the prevention of cross infection was first proven in
the 19
th
century (Su et al., 2015). In response to the increased number of HAIs, many
educational and informative strategies and campaigns were developed. National hospital
campaigns, global healthcare initiatives, and many quality-improvement strategies have
been developed to improve hand hygiene compliance among healthcare staff and have led
to a savings of up to $2.5 million annually per individual hospitals (Fox et al., 2014). All
the efforts that have been made place healthcare organizations on the right track, but with
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hand hygiene compliance less than 50% among healthcare staff, there is definite room for
improvement to save lives (CDC, 2017b). Maintaining motivation for compliance,
sustaining hand hygiene behavior after education, and providing feedback remains a
challenge. Too often improvements in compliance are short-term. According to the WHO
(2018b), main reasons for noncompliance reported by healthcare staff are: too busy, skin
irritation, glove use, and “don’t think about it.” Another major obstacle for hand hygiene
compliance is time constraint (WHO, 2018b). Adequate handwashing with water and
soap requires 20 seconds and with alcohol-based hand rubbing the requirement is 20 to
30 seconds (WHO, 2018b). The average time usually adopted by healthcare staff is less
than 10 seconds (WHO, 2018b). When digging deeper into the culture and behaviors of
healthcare staff on the two units, one observed area of opportunity for improvement was
performing hand hygiene after touching the patient environment. One study done by
Jackson and Griffiths (2014) suggested that hand hygiene is performed to protect the self,
rather than patient, and that a differentiation is made between “known” and “unknown”
dirt. It has also been found that healthcare staff perception of patient cleanliness is
affected by familiarity, and as familiarity with the patient grows, reluctance is reduced
(Jackson & Griffiths, 2014). Literature also indicates that hand hygiene compliance is
driven by behavior instead of scientific knowledge of infection control (Jackson &
Griffiths, 2014). The level of contamination or interventional task is too often how
healthcare staff are motivated to clean their hands. Workers are more motivated to clean
hands when performing tasks where there is a higher level of soiling such as visible soil
or a known risk of contamination. Certain tasks such as touching a patient or their
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environment, bedrails, clothing, patient’s skin, or checking blood pressure or temperature
are not perceived as a motivating factor to clean hands. According to WHO (2017), one
of the most common sources of transmission of infection is environmental surfaces.
Certain types of microbial bacteria are capable of surviving on environmental surfaces for
months at a time (WHO, 2017). When healthcare staff touch these surfaces the bacteria
can be transmitted, causing infection. For this reason, the “My 5 Moments of Hand
Hygiene” is the most effective hand hygiene guideline today. Healthcare staff must assess
the need to perform hand hygiene based on contamination, going from “dirty to clean.”
Looking at hand hygiene compliance even further, a study done by Melo et al., (2016)
concluded that there is no influence of morning or evening shifts on the performance of
hand hygiene by participants. Considering what is at stake, every effort should be
undertaken to improve hand hygiene compliance to prevent HAIs. Continuous education
is the best way healthcare staff can be reminded of the risk of HAIs associated with hand
hygiene noncompliance.
According to the WHO (2017), no health care facility in any country can be
considered HAI free. Globally, approximately 10% of patients in hospitals are affected by
HAIs, and the death rate among these patients is between 15% to 50%, with the vast
majority of these deaths being preventable (Ramos de Oliveira Douardo et al., 2017). In a
thorough, systematic analysis of 220 studies in developed countries done by Murni et al.
(2013), 4.5 to 7.1 out of 100 patients reported contracting an HAI during their hospital
stay. Although mostly preventable, HAIs cause more deaths than AIDS, breast cancer,
and car accidents combined (Marques et al., 2017).
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There is a lot of information available on hand hygiene compliance and the
prevention of HAIs through improved hand hygiene. I conducted a literature review on
organizational protocols and evidence-based guidelines gathered from scholarly peer-
reviewed studies from reliable sources, mostly through the Walden University Library. I
used search engines such as CINAHL, Medline, ProMed, and ScienceDirect with terms
such as HAIs, hospital infections, hand hygiene reeducation, and hand hygiene
compliance to find evidence-based data and information related to the project topic. The
main themes of this research include hand hygiene practices, compliance, preventing
hospital-acquired infections, reeducation as a strategy of improving compliance rates,
impact of hand hygiene noncompliance, and reeducation of healthcare staff. Reeducation
of healthcare staff in the organization and globally could enhance their understanding of
hand hygiene practices and the important role hand hygiene compliance plays in HAI
prevention and positive patient outcomes. Patients deserve to be safeguarded from any
preventable diseases during their hospital stay; to have a healthy and clean environment
that allows a positive progression towards healing. Evidence-based continuing education
is a common technique used in healthcare settings to improve clinical practice within the
scope of HAI prevention.
Role of the Doctor of Nursing Practice Student
My role as the DNP student was to review literature on evidence-based practice
regarding ways to best educate healthcare staff in an acute care setting on hand hygiene
practices and compliance and how it relates to HAI prevention. I used a multimodal hand
hygiene strategy, as recommended by the WHO, by developing educational posters and a
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PowerPoint presentation, using scenario-based education, and holding educational
sessions on hand hygiene practices and HAI prevention. My motivation for this project
was improving hand hygiene compliance rates to prevent HAIs.
Role of the Project Team
Multiple members of the partner organization oversaw the staff education
activities. The infection preventionist at the Southeast hospital guided me in developing
the educational sessions and materials based on the units’ needs and provided the data
collected on hand hygiene compliance 1month prior to and 1 month after the educational
sessions. The project team communication and activities were overseen by the principal
investigator and me. I developed educational materials and held educational sessions on
hand hygiene practices and HAI prevention over a period of 1 week.
Summary
The gap-in-practice identified in this project was hand hygiene compliance, and
the purpose of the project was improving hand hygiene practices by reeducating
healthcare staff to prevent HAIs. Florence Nightingale’s environmental theory was the
evidence-based practice model used for this project. Because healthcare staff are the
frontline of healthcare, they are expected to be diligent in ensuring positive patient
outcomes. Reeducation of healthcare staff equips them with increased knowledge on the
importance of preventing HAIs through better hand hygiene compliance. I gathered
literature such as organizational protocols and peer-reviewed evidence-based practice
guidelines and reviewed it for this project. I collected and reviewed literature, developed
hand-hygiene educational materials, and conducted educational sessions on hand hygiene
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practices and the role it plays in HAI prevention. Hand hygiene compliance rates were
collected for 1 month before and 1 month after the education sessions to evaluate the
effectiveness of the project. Information gathered in this section allowed for further
expansion of and detail for the project. Section 3 focuses on the collection and analysis of
evidence.
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Section 3: Collection and Analysis of Evidence
Introduction
HAIs are a global health concern. According to the CDC (2017), an estimated
722,000 HAIs occurred in acute care hospitals, and 75,000 of those patients died during
their hospitalization. The purpose of this project was to reeducate healthcare staff on hand
hygiene to prevent HAIs in an acute care setting. Section 2 of this project focused on
background and context. Topics included concepts and models used for the project, its
relevance to nursing practice, local background and context, and the role of the DNP
student in this project.
Section 3 centers on the practice-focused question, sources of evidence, and
analysis and synthesis of gathered data in more detail relating to hand hygiene and HAI
prevention in an acute care setting. This project compared hand hygiene compliance rates
for two hospital units before and after hand hygiene reeducation. The two hospital units
were a medical-surgical intensive care unit and a medical-surgical floor. Following
approval from Walden University Institutional Review Board (approval no. 08-08-18-
0736322) and the Organizational Institutional Review Board, hand hygiene compliance
rates on the two nursing units were reviewed 1 month before the reeducation and 1 month
after the reeducation. The reeducation sessions were held over the course of one week at
various times giving all healthcare staff an opportunity to participate.
The problem being addressed in this project was hand hygiene compliance in the
prevention of HAIs in an acute care setting. The goal was to provide hand hygiene
reeducation to healthcare staff to prevent HAIs. The gap-in-practice that this doctoral
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education project addressed was hand hygiene compliance and providing healthcare staff
reeducation on hand hygiene to prevent HAIs. The gap-in-practice was addressed through
the reeducation of healthcare staff on hand hygiene related to the prevention of HAIs.
The purpose of the project was better patient outcomes through infection prevention and
increased healthcare provider knowledge on the importance of hand hygiene compliance
in an acute care setting.
Practice-Focused Question
PFQ: Will reeducating healthcare staff regarding the importance and significance
of hand hygiene help improve hand hygiene compliance rates in an acute care
setting?
Definition of Terms
The following italicized phrases or words are defined for this DNP project.
Healthcare providers: A professional licensed member of a healthcare team such
as a registered nurse, a medical doctor, an advanced practice registered nurse, a physician
assistant, or a nursing assistant. These are professionals involved in providing patient care
and are required to follow hand-hygiene protocols to prevent HAIs in an acute care
setting.
Healthcare-associated infections: Infections that patients can get in a healthcare
facility, a major, yet mostly preventable, patient safety threat (CDC, 2017a). To be
considered an HAI, infections must be contracted by patients up to 48 hours after hospital
admission, up to 3 days after discharge, or up to 30 days after an operation (Stubblefield,
2016).
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Hand-hygiene: The act of cleaning one’s hands by either handwashing using soap
and water, antiseptic hand wash, or use of an antiseptic hand rub such as an alcohol-based
hand sanitizer (CDC, 2017b).
Acute care setting: A setting where patients receive short term medical treatment
for conditions such as acute illnesses, recovery from surgery, or an acute injury (WHO,
2013).
Sources of Evidence
Sources of systematic evidence that were collected for the purpose of meeting the
requirements for this DNP project included current organizational protocols and
evidence-based guidelines gathered from peer-reviewed studies from reliable sources
such as the hospital library and the university library. I used search engines such as
CINAHL, Medline, and ScienceDirect with search terms such as HAIs, hospital-acquired
infections, and hand hygiene to find information and evidence-based data for the project.
Data on hand hygiene compliance rates were collected 1 month before and 1 month after
the reeducation sessions using the organization’s electronic monitoring system. Analysis
of the evidence-based data focused on whether there was a significant change in the
variable that I was attempting to influence, which in this case was hand hygiene
compliance rates following reeducation. The evidence that was collected for this doctoral
project assisted me in addressing the gap in nursing practice through the development of
additional healthcare provider education on hand hygiene and the reduction of HAIs in an
acute care setting. Through this project, educational strategies were developed and used.
The practice focused question for this project was:
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PFQ: Will reeducating healthcare staff regarding the importance and significance
of hand hygiene help improve hand hygiene compliance rate in an acute care
setting?
Collection and analysis of evidence on the relationship between the healthcare
provider reeducation on hand hygiene and the healthcare staff’s understanding of HAI
prevention following nursing reeducation provided the appropriate way to address the
practice focused question. It was a way to show that the evidence was clear, strong,
present, and that a change was needed in hand hygiene habits among healthcare staff
when HAI prevention is the goal.
Participants
The individuals who participated in the educational sessions were nursing and
ancillary staff including respiratory, physical, occupational, and speech therapists, as well
as dietary, transport, laboratory, and housekeeping. The inclusion criteria for those
chosen to participate in the project were healthcare staff and ancillary staff who provide
patient care and perform routine hand hygiene; either by using soap and water or alcohol-
based sanitizer before and after providing patient care. Activities that do not require hand
hygiene were the exclusion criteria for this DNP project.
Procedures
Hand-hygiene posters, a PowerPoint presentation, and scenario-based education
were developed as part of the reeducational session by me based on the WHO’s “My 5
Moments of Hand Hygiene” guidelines adopted by the organization in 2010. Participants
were reeducated on the importance of hand hygiene compliance and its relevance to the
23
prevention of HAIs. All participants were given the opportunity to ask questions related
to data gathered on the DNP project topic, including statistics. Table 1 contains the
demographic characteristics of the DNP project participants measured.
Table 1
Demographic Characteristics of the Participants
________________________________________________________________________
Characteristics Number
Registered nurses/ Nursing assistants 73
Therapists (respiratory, physical, speech, occupational) 28
Ancillary (transport, dietary, lab, housekeeping) 81
Protections
Participants in this doctoral project were chosen based on the hospital unit they
work on. There were 182 registered nurses, nursing assistants, therapists, and ancillary
staff working on the medical-surgical and ICU units. Each participant was informed that
their participation in the project was not required and was voluntary. No confidential
information was gathered during the study. Participants were reeducated on hand hygiene
practices and the prevention of HAI.
Analysis and Synthesis
Direct observation, which has been the golden standard of hand hygiene
compliance data collection, has been shown to be skewed and flawed due to the
Hawthorne effect. The Hawthorne effect, also known as the observer effect, is a type of
reactivity in which an individual modifies an aspect of their behavior in response to their
24
awareness of being observed. Many healthcare organizations have moved towards
collecting hand hygiene compliance data electronically.
Hand hygiene compliance data was collected using an electronic monitoring
system. The monitoring system was developed through the collaboration of scientists,
researchers, and engineers along with healthcare leaders from medical, research, infection
prevention, and quality management specialties. Through the monitoring system, leaders
can measure compliance rates and share that information. Product usage data is collected
and transmitted wirelessly every time a hand sanitizer dispenser or a hand soap dispenser
is used. The monitoring does not require any special activity by healthcare staff. Data is
transmitted electronically to the corporation’s servers and is only available to authorized
hospital staff. Compliance rates are calculated according to a developed algorithm based
on the expected number of hand hygiene occurrences by unit type and for specific times
of day and days of the week. By dividing the number of opportunities into the number of
activations, the Hand Hygiene Compliance Index, also referred to as the rate, is
calculated. Hand hygiene compliance data is printed out and shared daily on the two
units.
Data was collected on a medical-surgical intensive care unit and a medical-
surgical floor. The Hand Hygiene Compliance Index for the small Southeast hospital is
combined for the two nursing units to stabilize the compliance rate due to variation in
census. The medical-surgical intensive care unit has eight beds and the medical-surgical
floor unit has 36 beds. Patients on these two units come from all backgrounds and are at
risk for infections such as central line-associated bloodstream infections, catheter-
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associated urinary tract infections, surgical site infections, ventilator-associated
pneumonia, Methicillin-resistant Staphylococcus aureus, Vancomycin-resistant
enterococci, Clostridium difficile, Escherichia coli, as well as others such as fungal
infections and skin infections.
The data analysis was an evaluation of whether hand hygiene compliance rates
increased following healthcare staff reeducation. Data was collected 1 month before and
1 month after the reeducation sessions from the electronic monitoring system. The mean
rates of hand hygiene compliance were estimated using descriptive statistics.
Recommendations were made regarding the outcome of reeducation.
Summary
Section 3 of this doctoral project included collection and analysis of evidence. I
introduced the topic of this project and restated the practice-focused question. I defined
terms frequently used in this DNP project and explained in detail how sources of
evidence were gathered. I identified the participants in the study along with the
procedures that were followed. I developed educational materials, and during educational
sessions, participants were reeducated on hand hygiene and the prevention of HAIs. I
informed participants that no personal identifiers were used during the project. After the
education was completed and hand hygiene compliance data was gathered, the next step
was to disclose findings and recommendations, both of which will be covered in Section
4.
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Section 4: Findings and Recommendations
Introduction
Poor hand hygiene compliance in an acute care setting is associated with
increased risk of HAIs and death of patients. Patient safety is a priority and improving
hand hygiene compliance rates is an effective way to reduce the risk of patients being
exposed to or contracting an HAI. According to the CDC (2017a), the estimated cases of
HAIs in the United States for 2014 were 722,000, and 75,000 of those patients died as a
result of their infection. With hand hygiene compliance as low as 50%, HAIs remain a
global challenge.
This project focused on addressing hand hygiene compliance among healthcare
staff in an acute care setting. The practice focused question was:
PFQ: Will reeducating healthcare staff regarding the importance and significance
of hand hygiene help improve hand hygiene compliance rates in an acute care
setting?
The purpose of this staff education project was to reeducate health care staff on hand
hygiene to prevent HAIs in an acute care setting and to provide recommendations
regarding the sustainability of the reeducation initiative.
Sources of evidence that I collected for this project included organizational
protocols and evidence-based guidelines gathered from peer-reviewed studies from
reliable sources such as the hospital library and the university library, I used search
engines such as CINAHL, Medline, and ScienceDirect. I collected data on hand hygiene
compliance rates 1 month before and 1 month after the reeducation sessions using the
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organization’s electronic monitoring system. Analysis of the data focused on whether
there was a significant change in hand hygiene compliance rates following reeducation. I
estimated the mean rates using descriptive statistics.
Findings and Implications
The site for this project was an 82-bed magnet-designated hospital in the
Southeast. Participants included all nursing and ancillary staff who care for patients on
the medical-surgical intensive care unit and a medical-surgical floor. Of the 182
anticipated participants, a total of 97 participated. The reeducation was based on the
WHO’s “My 5 Moments for Hand Hygiene” guideline adopted by the organization.
Hand-hygiene posters, a PowerPoint presentation, and scenario-based education were
used as tools for the multi-modal reeducation sessions. Sessions were held during both
day and night shifts for one week allowing an opportunity for all participants to attend.
Hand hygiene compliance rates were reviewed for 1 month before the reeducation and 1
month after the reeducation. The pre-education mean rate was 63% and the post-
education mean rate was 81%. The results showed that the educational intervention did
elicit a statistically significant change in hand hygiene compliance rates with an increase
of 18%.
One unanticipated limitation of the project was the number of participants. I
covered both day and night shifts as well as announced hand hygiene sessions overhead
throughout the hospital during the week, but the final participation was 54%. During the
planning stage the project team, which included the infection preventionist, set the
minimum participation goal at 50%, which would provide a reasonable starting point for
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the project to be considered successful, and the goal was narrowly surpassed. Hand
hygiene compliance rates increased after the reeducation and sustained for the month data
was collected.
Implications resulting from an increase in hand hygiene compliance rates among
healthcare staff include higher quality patient care, a decreased risk of patients acquiring
HAIs in an acute care setting resulting in a healthier community, and financial benefits
for the organization through reimbursements, decreased costs, increased patient
satisfaction, and better patient outcomes. The objectives of this doctoral project were to
reeducate healthcare staff regarding the importance of hand hygiene practices and
compliance to prevent HAIs and to provide recommendations regarding the sustainability
of the reeducation initiatives. The following goals and outcomes were met for this
project: (a) develop an evidence-based multimodal hand hygiene reeducation curriculum
for healthcare staff, (b) develop an evaluation plan, (c) carry out the educational sessions
over a 1 week period for both day and night shift for both unit staff and ancillary staff, (d)
compare hand hygiene compliance rates month before and 1 month following reeducation
of staff, and (e) provide recommendations regarding the sustainability of the reeducation
initiatives following the completion of the project.
Potential implications for positive social change resulting from an increase in
hand hygiene compliance rates include higher quality patient care, increased patient
satisfaction, and a decrease in HAI rates resulting in a decrease in economic burden for
organizations, patients, and the community.
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Recommendations
According to the gathered data, hand hygiene compliance rates increased by 18%
following healthcare staff reeducation. After multiple meetings and discussions, I along
with the team proposed solutions that will potentially address the lack of hand hygiene
compliance. The first recommendation was to discuss hand hygiene compliance rates
daily in the Safety Huddle following the multi-modal education, making it a daily focus.
The infection preventionist along with the nurse manager will evaluate compliance rates
by the hour and will conduct additional counseling to the staff working during the shifts
when compliance rates are low. The organization has implemented both
recommendations into their daily practice in the effort to sustain the higher compliance
rates seen following reeducation.
Contribution of the Doctoral Project Team
Multiple members of the organization participated in the completion and success
of the doctoral project. The principal investigator planned and organized all
communications among team members, approved educational materials, and supervised
all activities. The infection preventionist made the recommendations for the educational
materials based on the needs of the units and participated in some of the educational
sessions with me. I developed a multimodal educational plan and held a week-long
educational fair with one-on-one educational sessions on hand hygiene practices and HAI
prevention over a period of 1 week. Each member of the project team was involved in the
development of the final recommendations made to sustain hand hygiene compliance
rates on both units.
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Strengths and Limitations of the Project
Strengths:
One strength of the project was the inclusion of ancillary departments including
respiratory therapy, physical/speech/occupational therapy, laboratory, dietary,
housekeeping, and transport. Also, the available evidence-based literature on hand
hygiene compliance and HAI prevention was in abundance, and the extensive searches of
multiple databases that focused on the project topic contributed to the strength of the
project. Additionally, the data gathered using the electronic monitoring system adopted
by the organization was reliable, sufficient, relevant, and up-to-date, which helped in
drawing sufficient conclusions about the results. Another strength of the project was
teamwork. Each team member was equally invested in the success of the project.
Limitations:
One identified limitation of the project was not including the physicians in the
reeducation. Another limitation was that 46% of the healthcare staff did not participate in
the reeducational sessions. According to the WHO (2009), factors for improved
compliance among healthcare providers are education and training. Healthcare staff who
do not participate in education are more likely to continue same hand hygiene patterns
and behaviors (WHO, 2009).
