evidence based practice: handwashing...

Running head: EVIDENCE BASED PRACTICE: HANDWASHING COMPLIANCE 1

Evidence Based Practice: Hand Washing Compliance

Shawna Nietz, Melissa Kurek, Heidi Ertman, Sarah Rousseau and Molly Bach-Bullen

Ferris State University

EVIDENCE BASED PRACTICE: HAND WASHING COMPLIANCE 2

Abstract

The topic of the paper pertains to hand washing compliance among nurses. From the time,

Florence Nightingale investigated the correlation between proper hand hygiene and the health of

the patients she cared for, hand hygiene has been a first line instrument to prevent infections. The

purpose of this project is to demonstrate the ability to analyze evidence based research articles

regarding hand washing and to use the findings to enhance current practice. A descriptive

summary of the five original research articles are include within the contents of this paper. The

evidence of each of these articles is critically analyzed for reliability and personal experiences

regarding hand hygiene. A recommendation for the utilization of the current research into

nursing evidence-based practice is reviewed. The objective of this project is to improve the

students nursing practices by enabling them to apply evidence based research regarding hand

washing and utilize the findings in their current practice.

EVIDENCE BASED PRACTICE: HAND WASHING COMPLIANCE 3

Evidence Based Practice: Hand Washing Compliance

Ignaz Semmelweiz and Florence Nightingale proved the correlation between hand

washing and patient health in the 1800s. Yet many health care workers today do not practice this

on a regular basis, leading to increased levels of nosocomial infections “Studies have shown that

contamination from the hands of health care professionals is the primary factor for the spread of

hospital infections involving the urinary system, lower respiratory tract, and surgical site

infections” (Celik & Kocash, 2008, p.207). While it seems clear that health care workers should

be aware of the importance of hand hygiene, many still forget to perform hand hygiene on the

way in and out of a patient’s room. “Each year, an estimated 2.5 million patients in the United

States develop health care- associated infections that result in 90,000 deaths and cost the health

care system an estimated $4.5 to $5.7 billion dollars” (Korniewicz & El-Masri, 2008, p. 86).

The aim for this paper is to analyze and interpret literature regarding hand-washing

compliance among nurses. The evidence gained from research allows the recognition of

healthcare deficiencies, leading to implications for nursing practice changes. As nurses, we need

to be aware of evidence based research studies on hand washing, the results obtained and how to

encourage compliance in the clinical setting.

Descriptive Summary of Evidence

Most nurses know the importance of hand washing yet, the majority of nurses do not

perform this while giving direct patient care. After reading and analyzing the literature, it was

found in every study that hand washing compliance is low among all healthcare workers. We

have to ask the question why are health care workers, not doing what is acknowledged to be the

correct course of action – washing our hands when entering and leaving patient’s rooms?

EVIDENCE BASED PRACTICE: HANDWASHING COMPLIANCE 4

Hygienic Hand Washing Among Nursing Students in Turkey

In the Celik & Kocash (2006) journal article reviewing hand washing among nursing

students, it was found that hand washing rates were low. This report is based on 430 nursing

student’s responses to a fifteen-question questionnaire regarding hand-washing techniques. The

nursing students self reports of their hand washing rates were higher than their actual hand

washing rates when compared to the amount of direct patient care given (Celik & Kocash, 2006).

Factors that contributed to the lack of hand washing included: difficult workloads, the lack of

sink convenience, and the student nurses perceptions of washing their hands enough. The authors

suggested that “it is important that academic instructors and clinical instructors keep students’

knowledge of the subject updated during clinical application and that they act as role models of

hand washing and give frequent feedback to students so as to improve the rate of hand washing”

(Celik & Kocash, 2006, p.210).

Exploring the Factors Associated with Hand Hygiene Compliance of Nurses during

Routine Clinical Practice

Korniewicz & El-Masri (2008) examined hand-washing compliance among health care

providers. Forty-seven nurses participated in a sixteen-week observational study conducted on

an oncology unit. The research assistants visually observed the health care providers giving care

and compared their observations with the instrumentation of seven open-ended questions

pertaining to the visual observations witnessed. The purpose of this study was to examine hand

hygiene compliance before and after patient care. Overall, the test results demonstrated that

“hand hygiene compliance rate was 41.7% before procedure and 72.1% after the procedure. The

overall compliance was only 34.3%” (Korniewicz & El-Marsi, 2008, p.88). Factors found

negatively affecting hand washing included: healthcare workers perception of their hands as not


being dirty, lower adherence to hand washing when not dealing with blood, and when risk for

infection is low. The authors concluded that the hand hygiene compliance is low and continues

to be a major issue in the healthcare field.

Nurses’ Motivation to Wash Their Hands: A Standardized Measurement Approach

O’Boyle, Henly, & Duckett (2001) conducted a study which assessed the motivation of

nurses in regards to hand washing. The study is composed of 120 registered nurses from four

nonprofit community hospitals. The nurses each completed a written hand-washing assessment

instrument and after completion, they were observed for two hours on their hand washing

behaviors (O’Boyle et al., 2001). The hand washing assessment instrument revealed that nurses

realize the importance of hand washing but at times find they are too busy to maintain

compliance. “Hand washing was regarded in positive terms as an obligation to their patients, but

nurses in the focus group also acknowledged that recommended hand washing practices were

less likely to occur when the clinical setting was busy” (O’Boyle et al., 2001, p.144).

Hand Hygiene Behavior in a Pediatric Emergency Department and a Pediatric Intensive

Care Unit: Comparison of Use of 2 Dispenser Systems

The study conducted in a pediatric emergency and intensive care unit by Larson, Albrecht

& O’Keefe (2005) compared hand hygiene compliance with the use of operated sanitizer

dispensers versus manually operated sanitizer dispensers and direct observations. Each of the

dispensers contained electronic counting devices. The counting devices were also installed in the

soap dispensers, and research assistants recorded compliance using a hand hygiene observation

instrument. “Based on the indications for compliance with the Center for Disease Control and

prevention’s guidelines for hand hygiene, this study found a 38% compliance rate for hand

hygiene activities, with no difference between the emergency department and the pediatric


intensive care unit” (Larson et al., 2005, p.307). The authors for this study also stated that hand

hygiene with the battery operated touch free sanitizer was found to be used more frequently then

the manual soap dispenser.

Behavioral Determinants of Hand Hygiene Compliance in Intensive Care Units

Wandel, Maes, Labeau, Vereecken, & Blot (2010) conducted a study about factors

associated with a nurse’s noncompliance with hand hygiene. The study consisted of 148 nurses

on a forty bed intensive care unit. The participants were given a fifty six question test regarding

hand washing. The results from the questionnaire suggested that “neither having good theoretical

knowledge of hand hygiene guidelines or social influence or moral perceptions had any

predictive value relative to hand hygiene practice” (Wandel, et al., 2010, p.230). The authors

concluded that compliance rates were decreased when the nurse’s attitudes were pessimistic

about hand washing education and techniques.

Analysis of the Evidence

Hygienic Hand Washing Among Nursing Students in Turkey

This study focuses on 430 nursing students’ perceptions of hand washing techniques of

second, third and fourth year nursing students. The participants filled out a fifteen-question

questionnaire pertaining to demographic characteristics, clinical practice area, patient care

activities, reasons for hand washing, and the type of hand washing agents used (Celik & Kocash,

2006). The data collection and recording processes were explained and conducted professionally

and appropriately. The aim for this study was “to determine the application status of hand-

washing information given within the context of infection control measures in practice areas

among nursing students” (Celik & Kocash, 2006, p.207).


The results of this study should be used toward evidence-based practice however; the

study should not stand alone as evidence to support hand washing compliance and perceptions.

The researchers of the study state that further research is needed to verify and clarify the results.

This study has proven that hand-washing perceptions vary and the student nurses knowledge of

hand washing is significantly higher than compliance.

Exploring the Factors Associated with Hand Hygiene Compliance of Nurses during

Routine Clinical Practice

In the study by Korniewicz & El-Masri (2008) examine the causes related to hand

washing compliance during patient care. The study consisted of forty-seven participants

observed by a research assistant over a sixteen-week period. The research was conducted at a

South Florida university oncology hospital. The data suggested that hand hygiene compliance

after giving direct patient care was higher than before the patient care was given. The researchers

believe that this may be that the nurses feel that they have to protect themselves more than their

patients (Korniewiz & El-Masri, 2008). The research concluded overall hand hygiene

compliance scored low and hand hygiene when working with blood increased.

The first limitation was the observational nature of the study. When the nurses were

observed they might have been more compliant with their hand hygiene practices. Another

limitation would be the threat of the Hawthorne effect on the validity of the results. The

Hawthorne effect occurs when the study participants respond in a certain way because they are

being observed (Nieswiadomy, 2008). The researchers believe that “regardless of these

limitations, our findings shed light on the issue of hand hygiene practices in acute health care

settings and the factors impacting these practices” (Korniewiz & El-Masri, 2008, p. 89).


The researchers believe the study could have expanded more with the use of video

monitoring of hand hygiene and observational feedback regarding hand hygiene. It was also

suggested that disciplinary ramifications should be conducted if there is failure to comply with

hand washing standards (Korniewiz & El-Masri, 2008). These types of actions may improve the

quality of hand hygiene given to patients.

Nurses’ Motivation to Wash Their Hands: A Standardized Measurement Approach

O’Boyle, Henly, & Duckett (2001) studied the motivation behind health care workers

hand washing compliance. This study used data from 120 nurses. The nurses were asked to

complete a hand washing assessment instrument, and after the completion allow themselves to be

observed for up to two hours. When the nurses were observed, the Hawthorne effect may have

occurred and caused doubt as to the dependability of the results of the study.

A combination of tools were used to measure hand washing motivation, which included

examining the variables that were observed by the researchers and the hand washing assessment

instrument questionnaire. The hand assessment instrument is a method for measuring values,

beliefs, and feelings of nurses in regards to hand washing (O’Boyle et al., 2001). It was

concluded from the assessment that infections and protection for one self were huge motivators

for hand hygiene.

The researchers for this study stated that additional research is needed to examine the

nurse’s thoughts in answering the assessment with socially desirable answers versus what the

nurse really feels. Also, a continuing study related to nurse’s frustrations with workloads on hand

motivations were suggested. Detailed records were kept of the data collection, and informed

consent and ethics approval was properly obtained. The researchers described the criterion for

the participants.


Hand Hygiene Behavior in a Pediatric Emergency Department and a Pediatric Intensive

Care Unit: Comparison of Use of 2 Dispenser Systems

The aim for the study conducted by Larson, Albrecht, & O’Keefe (2005) was to compare

the regularity of use with a manually operated and a touch-free battery operated hand sanitizer.

The researchers used a crossover intervention trial that allowed the dispensers to be placed on

two different hospital units (Larson et al., 2005). Research assistants conducted direct

observations for four months during different times of the day for fifteen hours a week.

Research assistants did round on two different hospital units. For this study, a hand hygiene

observation instrument was developed for the research assistant to use when observing hand-

washing behaviors. It was observed that “ the most frequent indications for hand hygiene were as

follows: before direct contact with a patient, after touching a patients intake skin, after contact

with inanimate objects in a patients vicinity, and after removing gloves” (Larson et al., 2005,

p.306).

In order to analyze the data for the manual and touch-free hand dispensers, each

dispenser contained electronic counting devises. The devices numbers were compared to the

census of patients on the two units. It was found that “the mean number of dispenser hits for both

types of dispensers, controlled for patient census, was significantly lower in the emergency

department than in the pediatric intensive care unit” (Larson et al., 2005, p.307).

The first limitation of this study is the placement of the dispensers. The touch-free

dispensers were placed high on the walls next to the manual dispensers and this could have

resulted in poor dispense of the sanitizer. The second limitation was the counting of the

electronic devices. The researcher counted each hit towards an incident of hand hygiene. This

could have resulted in higher hand hygiene rates due to a healthcare worker may have hit the


dispenser a few times. The third limitation was the location of the experiment. This study was

conducted in a pediatric emergency room and a pediatric intensive care unit. These locations do

not make up a general hospital setting. Finally, the period for the research was fifteen weeks. To

get a better estimate of hand hygiene behavior, the researcher suggested extending the period for

the experiment. The results of this study are beneficial in nursing education because it examines

factors that influence hand hygiene.

Behavioral Determinants of Hand Hygiene Compliance in Intensive Care Units

Wandel, Maes, Labeau, Vereecken, & Blot (2010) conducted a study about factors

associated with nurses’ noncompliance with hand hygiene. This study was conducted on 148

nurses working on a forty-bed intensive care unit in Ghent University Hospital. The researchers

developed a questionnaire involving the factors associated among nurses’ non-compliance with

hand hygiene. The questionnaire consisted of “self reported compliance scale (12 items, based on

the guidelines from the Centers for Disease Control and Prevention) and questions about

attitudes toward hand hygiene (12 items), social influence (10 items), self-efficacy (10 items),

and knowledge about hand hygiene (12 items)” (Wandel, et al., 2010, p.231). The researchers

assessed the reliability of the questionnaire by a test-retest method. Of the 148 nurses, only 108

responded to the test and 57 of the 148 nurses took the re-test. 57 of the total 148 nurses took

both tests (Wandel, et al., 2010).

The results obtained, illustrated that nurses’ knowledge of proper hand washing did not

increase hand washing compliance, and nurses with pessimistic attitudes and low self-efficacy

were shown to be less compliant. The study reinforces the need to educate nurses in regards to

hand hygiene.


The limitation in this study is the questionnaire. The researcher suggested “that when

self-reporting behavior is used, respondents tend to over score socially desirable behavior at up

to 3 times the observed compliance rates. Respondents also seem to have unrealistic estimations

of their own behavior” (Wandel, et al., 2010, p.235). Another limitation to the study is the time-

frame between the tests and re-tests. The participants may have discussed questions amongst

each other therefore, resulting in a better score on the re-test. The researchers suggest future

research using a qualitative approach including the effect of feedback on nurses’ self-perception

and attitude would be beneficial (Wandel, et al., 2010).

Personal Experiences

In 2009, Munson Medical Center held a yearly Universal Skills Day. One of the stations

nurses were required to attend was a hand washing station where nurses were asked to wash or

sanitize their hands. Once the nurses completed their hand hygiene, they held their hands under

a black light. The black light revealed the leftover bacteria after proper hand hygiene. The skills

station gave a visual aid and reminder to nurses to perform hand hygiene before and after patient

care.

Group two feels that poor hand hygiene is the most common complaint communicated by

patients through hospital stay surveys. As stated above, improper hand-hygiene can harm

patients and staff members. Healthcare workers may believe that only high-risk procedures are

worthy of hand hygiene compliance, but understanding all contact with patients puts the patients

and healthcare workers at risk for exposure and transmission of nosocomial infections. Non-

compliance with hand hygiene can prolong hospital stays among patients.

The decision to utilize all the information on hand washing is an individual one. Group

two believes personal experience, patient opinions, nursing in-services on a regular basis, and


rewards given by upper hospital personal when caught demonstrating hand hygiene would

increase hand hygiene adherence. Evidence-based practice demonstrating good hand washing

cannot be overrated; it decreases the spread of infection, decreases hospital costs, and even

protects lives.

Recommendations

Informing staff of the importance of hand hygiene is not enough. “Although the Centers

for Disease Control and Prevention and the Association for Professionals in Infection Control

and Epidemiology stated that hand washing is the most important approach to preventing

hospital infections, the hand- washing compliance rate among healthcare professionals is lower

than 50 %”( Celik & Kocash, 2006, p.207). Consequently, the effects of poor hand hygiene is

resulting in an increased number of hospital acquired infections. With statistics lower than 50%,

it is easy to see this is an area requiring evidence based practice implementation.

Based on personal experience, the hand washing station implemented at Munson Medical

Center was a success. Group two recommends that other acute care facilities focus on the

application of a similar hand washing station. Nursing staff must be educated of the importance

of healthy hand hygiene for each patient along with the continued feedback on patient stay

surveys.

What does the literature reveal about the lack of hand hygiene among nursing staff?

Overall, there is overwhelming evidence suggesting that nurses are aware of hand washing

knowledge, but do not use this knowledge in their nursing practices. Each study supported the

correlation between hand hygiene and lack of nurse’s compliance. All of the studies focused on

the same issue and they all provided evidence that the majority of healthcare workers lacked in


proper hand hygiene techniques. Group two believes this is an area of great importance and will

share the evidence-based results of this project with nursing colleagues as able.


References

Celik, S., & Kocash. S. (2006). Hygienic hand washing among nursing students in turkey.

Applied Nursing Research, 21(4), 207-211.doi: 10.1016/j.apnr.2006.12.001

Korniewicz, D.M., & El-Masri, M. (2008). Exploring the factors associated with hand hygiene

compliance of nurses during routine clinical practice. Applied Nursing Research, 23(2),

86-90. doi:10.1016/j.apnr.2008.06.002

Larson, E.L., Albrecht, S., & O’Keefe, M. (2005). Hand hygiene behavior in a pediatric

emergency department and a pediatric intensive care unit: Comparison of use of 2

dispenser systems. American Journal of Critical Care, 14(4), 304-310. Retrieved from

http://aacnjournals.org

Nieswiadomy, R.M. (2008). Foundations of nursing research (5th Ed.). Upper Saddle River,

N J: Prentice Hall.

O’Boyle, C. A., Henly, S. J., & Duckett, L. J. (2001). Nurses motivation to wash their hands: A

standardized measurement approach. Applied Nursing Research, 14(3), 136-145.

doi:10.1053/apnr.2001.24412

Wandel, D. D., Maes, L., Labeau, S., Vereecken, C., & Blot, S. (2010). Behavior determinants

of hand hygiene compliance in intensive care units. American Journal of Critical Care,

19(3), 230-239. Retrieved from http://aacnjournals.org


Paper #1 Evidence-Based Group Project Paper

Grading CriteriaHeadings Possible

PointsPoints Earned

Comments

Introduction:What is the problem or question; Provide support for relevance of the

question; Clearly describe the aim of the project & paper)

10

A descriptive summary of the most relevant & best evidence

to answer the research question (there is not analysis here, just a description of what you found in the literature) A

minimum of 5 original NURSINGresearch studies

must be cited!

10

An analysis of the evidence (this is a critical appraisal of the evidence and what you feel as a group the evidence suggests and whether there is strong or weak

evidence to support the suggested findings)

20

Describe how the evidence is affected by your experiences

as nurses, patient preferences, nursing's or other's values and

how these factors would influence your decision to

utilize the evidence in practice

20

Make a recommendation as to whether or not to utilize the

evidence (support your recommendation with rationale)

20

APA Format:Title page, abstract, headersMargins,

spacing, and headings

10

Sentence structure, spelling, grammar & punctuationStays

within the 8-10 page length excluding title, abstract, and

reference pages.

10

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