scholarship of Application

1

Addressing Low Hand Hygiene Compliance in an Intensive Care Unit

Student’s Name

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Instructor

Date

Addressing Low Hand Hygiene Compliance in an Intensive Care Unit

Hospital-acquired infections (HAIs) have a pooled prevalence of 32% among adults in intensive care units globally, contributing to significant morbidity, mortality, and healthcare costs (Odoom et al., 2025). The adherence to hand hygiene in low-resource settings is extremely low, typically ranging between 30 and 40 percent in critical care settings, which increases the risk of infection (Alshagrawi and Alhodaithy, 2024). This is of special concern to intensive care units (ICUs), where vulnerable patients are at increased risk. The issue of hand hygiene compliance must be addressed as a method of enhancing patient safety and adhering to evidence-based recommendations. This paper is intended to outline a practice issue connected to the low rates of hand hygiene compliance in an ICU, develop a problem statement and AIM statement, and utilize the Theory of Planned Behavior as a framework to implement interventions.

Practice Setting

The problem was identified during observations in the ICU of an urban tertiary hospital in Orlando, Florida, a previous practice site. It is a 20-bed inpatient facility that operates in a resource-limited environment, serving a wide range of population members with critical care services to the medical and surgical patients. The ICU is a high-volume environment that has emergencies, recoveries after an operation, and chronic diseases, and staffing ratios are often above 1:4 nurses to patients. Basic handwashing stations with soap and alcohol-based sanitizers are also in place, although the supply chains are not consistent and the workload is high, which leads to the departure of best practices. This environment is reflective of what happens in most hospitals in the urban U.S., where the issue of overcrowding and limited resources increases the problem of infection control.

Population

The affected population is comprised of critically ill adults aged 18-85 years, with common diagnoses including sepsis, respiratory failure, trauma, and post-surgical complications. Cultural aspects are also at work, with patients of different ethnic backgrounds (e.g., Hispanic, African American) possibly having different health beliefs that affect their family involvement in the care. Language barriers exist, with English and Spanish predominant, but some patients require interpreters. Social economic inequalities come into play, where most of the low-income urban areas have an uphill struggle to get care. These attributes imply specific interventions since older patients (over 65, 40% of admissions) and patients with comorbidities are especially vulnerable to HAIs because of poor immunity and long-term use of ventilators.

Description of the Problem

The problem involves suboptimal hand hygiene compliance among healthcare workers (HCWs), leading to elevated HAI rates. Observations from the setting revealed compliance rates around 25-60%, far below recommended thresholds for effective infection prevention (Bredin et al., 2022). Data that led to this identification included infection surveillance reports of a 14-18% HAI incidence, mostly central line-associated bloodstream infections (CLABSIs) and ventilator-associated events (VAEs), which were negatively correlated with observed hand hygiene adherence (r = -0.42) (Chakma et al., 2024). The existing practices are not based on the guidelines of the WHO on My 5 Moments of Hand Hygiene, where HCWs frequently do not sanitize themselves after contact with a patient or the environment because of time constraints, insufficient supplies, and habitual omissions. This lack of alignment with evidence-based practices leads to avoidable infections, prolonged hospitalizations, and antimicrobial resistance.

Problem Statement

In the ICU of an urban tertiary hospital, critically ill adult patients experience elevated HAIs due to HCWs' low hand hygiene compliance (averaging 37%), deviating from guidelines that recommend high adherence to prevent up to 50% of avoidable infections, necessitating targeted behavioral interventions to improve practices and reduce infection rates (Alshagrawi & Alhodaithy, 2024).

AIM Statement

To improve hand hygiene compliance among all HCWs in the ICU from a baseline of 50% to 90% by implementing targeted education, reminders, and supply enhancements within six months, as measured by direct observation and product consumption tracking.

Framework

The Theory of Planned Behavior (TPB) serves as the guiding framework for addressing this problem. TPB assumes that the behavioral intentions depend on the three basic constructs, namely attitudes towards the behavior, subjective norms, and perceived behavioral control (Bulbul Maras and Kocacal, 2024). Here the attitudes are the beliefs of HCWs regarding the benefits of hand hygiene, including the reduction of HAIs; subjective norms include the perceived social pressures of their colleagues and leadership; and the perceived control consists of the barriers of resources availability and self-efficacy in high-stress settings.

This framework is directly related to the components of the problem. An example of low compliance is usually a result of negative attitudes (e.g., thinking hand hygiene is time-wasting) and weak norms (e.g., no peer accountability), which TPB can help to overcome by using attitude-shifting education and norm-building campaigns (Bulbul Maras and Kocacal, 2024). Interventions to counter the issue involve surveys to measure the intentions at baseline, specific training to increase perceived control (e.g., practice in simulation), and leadership approvals to reinforce the norms. TPB promotes quantifiable changes since it predicts and affects intentions, which can be seen in research where TPB-based interventions have increased compliance by 20-30% (Sin et al., 2022). Compared to quality improvement models, TPB offers a psychological perspective of how to explain and change behaviors that cause the deviation of guidelines, making the change sustainable.

Conclusion

This paper outlined low hand hygiene compliance in an ICU as a critical practice problem, described the setting and population, and formulated a problem statement and AIM statement to drive change. The Theory of Planned Behavior offers a robust framework to correlate with problem elements and guide interventions, emphasizing behavioral predictors for improved outcomes. Addressing this issue is vital for enhancing patient safety and reducing HAIs in resource-limited settings.

References

Alshagrawi, S., & Alhodaithy, N. (2024). Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study. BMC Public Health, 24, 2333. https://doi.org/10.1186/s12889-024-19461-2

Bredin, D., O'Doherty, A., Hannigan, A., & Kingston, P. (2022). Hand hygiene compliance by direct observation in physician and nurse hospital wards: a systematic review and meta-analysis. Journal of Hospital Infection, 130, 20-33. https://doi.org/10.1016/j.jhin.2022.08.013

Bülbül Maraş, G., & Kocaçal, E. (2024). Exploring determinants of hand hygiene among nursing students: A theory of planned behavior approach. BMC Nursing, 23, 406. https://link.springer.com/article/10.1186/s12912-024-02062-0

Chakma, S. K., Sadique, M. Z. A., Sing, A. K., Kabir, M. F., Islam, M. S., Islam, M. R., & Siddiqui, M. A. (2024). Effectiveness of a hand hygiene training intervention in improving knowledge and compliance rate among healthcare workers in a respiratory disease hospital. Heliyon, 10(5), e27286. https://www.cell.com/heliyon/fulltext/S2405-8440(24)03317-6?uuid=uuid%3A116ac320-4fa6-45f4-86a0-3f82fc46ec24

Odoom, A., & Donkor, E. S. (2025). Prevalence of Healthcare‐Acquired Infections Among Adults in Intensive Care Units: A Systematic Review and Meta‐Analysis.  Health Science Reports,  8(7), e70939. https://pmc.ncbi.nlm.nih.gov/articles/PMC12239516

Sin, C. S., Rocha, J. L., Lee, R. K. Y., Wong, L. W. Y., & Suen, L. K. P. (2022). Using the theory of planned behaviour to explain hand hygiene among nurses in Hong Kong during COVID-19. Journal of Hospital Infection, 123, 119-125. https://doi.org/10.1016/j.jhin.2022.01.018

1

Addressing Low Hand Hygiene Compliance in an Intensive Care Unit

Student’s Name

Institutional Affiliation

Course

Instructor

Date

Addressing Low Hand Hygiene Compliance in an Intensive Care Unit

Hospital-acquired infections (HAIs) have a pooled prevalence of 32% among adults in intensive care units globally, contributing to significant morbidity, mortality, and healthcare costs (Odoom et al., 2025). The adherence to hand hygiene in low-resource settings is extremely low, typically ranging between 30 and 40 percent in critical care settings, which increases the risk of infection (Alshagrawi and Alhodaithy, 2024). This is of special concern to intensive care units (ICUs), where vulnerable patients are at increased risk. The issue of hand hygiene compliance must be addressed as a method of enhancing patient safety and adhering to evidence-based recommendations. This paper is intended to outline a practice issue connected to the low rates of hand hygiene compliance in an ICU, develop a problem statement and AIM statement, and utilize the Theory of Planned Behavior as a framework to implement interventions.

Practice Setting

The problem was identified during observations in the ICU of an urban tertiary hospital in Orlando, Florida, a previous practice site. It is a 20-bed inpatient facility that operates in a resource-limited environment, serving a wide range of population members with critical care services to the medical and surgical patients. The ICU is a high-volume environment that has emergencies, recoveries after an operation, and chronic diseases, and staffing ratios are often above 1:4 nurses to patients. Basic handwashing stations with soap and alcohol-based sanitizers are also in place, although the supply chains are not consistent and the workload is high, which leads to the departure of best practices. This environment is reflective of what happens in most hospitals in the urban U.S., where the issue of overcrowding and limited resources increases the problem of infection control.

Population

The affected population is comprised of critically ill adults aged 18-85 years, with common diagnoses including sepsis, respiratory failure, trauma, and post-surgical complications. Cultural aspects are also at work, with patients of different ethnic backgrounds (e.g., Hispanic, African American) possibly having different health beliefs that affect their family involvement in the care. Language barriers exist, with English and Spanish predominant, but some patients require interpreters. Social economic inequalities come into play, where most of the low-income urban areas have an uphill struggle to get care. These attributes imply specific interventions since older patients (over 65, 40% of admissions) and patients with comorbidities are especially vulnerable to HAIs because of poor immunity and long-term use of ventilators.

Description of the Problem

The problem involves suboptimal hand hygiene compliance among healthcare workers (HCWs), leading to elevated HAI rates. Observations from the setting revealed compliance rates around 25-60%, far below recommended thresholds for effective infection prevention (Bredin et al., 2022). Data that led to this identification included infection surveillance reports of a 14-18% HAI incidence, mostly central line-associated bloodstream infections (CLABSIs) and ventilator-associated events (VAEs), which were negatively correlated with observed hand hygiene adherence (r = -0.42) (Chakma et al., 2024). The existing practices are not based on the guidelines of the WHO on My 5 Moments of Hand Hygiene, where HCWs frequently do not sanitize themselves after contact with a patient or the environment because of time constraints, insufficient supplies, and habitual omissions. This lack of alignment with evidence-based practices leads to avoidable infections, prolonged hospitalizations, and antimicrobial resistance.

Problem Statement

In the ICU of an urban tertiary hospital, critically ill adult patients experience elevated HAIs due to HCWs' low hand hygiene compliance (averaging 37%), deviating from guidelines that recommend high adherence to prevent up to 50% of avoidable infections, necessitating targeted behavioral interventions to improve practices and reduce infection rates (Alshagrawi & Alhodaithy, 2024).

AIM Statement

To improve hand hygiene compliance among all HCWs in the ICU from a baseline of 50% to 90% by implementing targeted education, reminders, and supply enhancements within six months, as measured by direct observation and product consumption tracking.

Framework

The Theory of Planned Behavior (TPB) serves as the guiding framework for addressing this problem. TPB assumes that the behavioral intentions depend on the three basic constructs, namely attitudes towards the behavior, subjective norms, and perceived behavioral control (Bulbul Maras and Kocacal, 2024). Here the attitudes are the beliefs of HCWs regarding the benefits of hand hygiene, including the reduction of HAIs; subjective norms include the perceived social pressures of their colleagues and leadership; and the perceived control consists of the barriers of resources availability and self-efficacy in high-stress settings.

This framework is directly related to the components of the problem. An example of low compliance is usually a result of negative attitudes (e.g., thinking hand hygiene is time-wasting) and weak norms (e.g., no peer accountability), which TPB can help to overcome by using attitude-shifting education and norm-building campaigns (Bulbul Maras and Kocacal, 2024). Interventions to counter the issue involve surveys to measure the intentions at baseline, specific training to increase perceived control (e.g., practice in simulation), and leadership approvals to reinforce the norms. TPB promotes quantifiable changes since it predicts and affects intentions, which can be seen in research where TPB-based interventions have increased compliance by 20-30% (Sin et al., 2022). Compared to quality improvement models, TPB offers a psychological perspective of how to explain and change behaviors that cause the deviation of guidelines, making the change sustainable.

Conclusion

This paper outlined low hand hygiene compliance in an ICU as a critical practice problem, described the setting and population, and formulated a problem statement and AIM statement to drive change. The Theory of Planned Behavior offers a robust framework to correlate with problem elements and guide interventions, emphasizing behavioral predictors for improved outcomes. Addressing this issue is vital for enhancing patient safety and reducing HAIs in resource-limited settings.

References

Alshagrawi, S., & Alhodaithy, N. (2024). Determinants of hand hygiene compliance among healthcare workers in intensive care units: a qualitative study. BMC Public Health, 24, 2333. https://doi.org/10.1186/s12889-024-19461-2

Bredin, D., O'Doherty, A., Hannigan, A., & Kingston, P. (2022). Hand hygiene compliance by direct observation in physician and nurse hospital wards: a systematic review and meta-analysis. Journal of Hospital Infection, 130, 20-33. https://doi.org/10.1016/j.jhin.2022.08.013

Bülbül Maraş, G., & Kocaçal, E. (2024). Exploring determinants of hand hygiene among nursing students: A theory of planned behavior approach. BMC Nursing, 23, 406. https://link.springer.com/article/10.1186/s12912-024-02062-0

Chakma, S. K., Sadique, M. Z. A., Sing, A. K., Kabir, M. F., Islam, M. S., Islam, M. R., & Siddiqui, M. A. (2024). Effectiveness of a hand hygiene training intervention in improving knowledge and compliance rate among healthcare workers in a respiratory disease hospital. Heliyon, 10(5), e27286. https://www.cell.com/heliyon/fulltext/S2405-8440(24)03317-6?uuid=uuid%3A116ac320-4fa6-45f4-86a0-3f82fc46ec24

Odoom, A., & Donkor, E. S. (2025). Prevalence of Healthcare‐Acquired Infections Among Adults in Intensive Care Units: A Systematic Review and Meta‐Analysis.  Health Science Reports,  8(7), e70939. https://pmc.ncbi.nlm.nih.gov/articles/PMC12239516

Sin, C. S., Rocha, J. L., Lee, R. K. Y., Wong, L. W. Y., & Suen, L. K. P. (2022). Using the theory of planned behaviour to explain hand hygiene among nurses in Hong Kong during COVID-19. Journal of Hospital Infection, 123, 119-125. https://doi.org/10.1016/j.jhin.2022.01.018