Nurse Education on Handwashing to Reduce Hospital-Acquired Infections

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Nurse Education on handwashing

The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) continues to be a useful tool for research. It is a helpful guide for developing questions in an attempt to find evidence (Dearholt & Dang, 2012). This tool is used to make the current study informative particularly focusing on the identification of the problem and its importance, as well as current practice, the focus of the problem, its scope, and most importantly, the development of the research question.

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Hospital-acquired infections remain a major problem in healthcare systems and are often associated with mortality and morbidity, apart from being an economic burden. Nonetheless, hand hygiene such as hand washing using water and detergent or alcohol-based hand sanitizers continues to be a very useful method of preventing the transmission of such infections. Similarly, compliance with the hand hygiene requirements is reported to be an important approach for minimizing the transmission of disease-causing organisms in the health care setting. Among various health care workers, nurses are at an increased risk of transmitting hospital-acquired infections because they spend more time with patients than any of the other categories of health caregivers (Fox et al., 2015). However, nurses can also use their professional knowledge on the importance of hand hygiene, especially hand washing to educate patients. Nurses have a great opportunity to promote hand hygiene by providing education to their clients. Therefore, the current study seeks to determine whether nurses’ education on handwashing in intensive care units may reduce the rate of hospital-acquired infections transmission.

Practice/PICO Question

This study utilizes the population (P), intervention (I), comparison (C), and outcome (O) format. The format has been chosen because it is appropriate for evidence-based investigations. The question for this case is the following. Among patients admitted in hospitals (P), does nurse education on handwashing (I), compared to no handwashing education (C), help to reduce hospital-acquired infections (O)?

Search Strategy

The databases that have been chosen include Cochrane, PubMed, MEDLINE, EMBASE, and CINAHL, recommended by most evidence-based guides and being highly appraised by health care practitioners. Besides, the databases are in free availability, being easy to look through and self-described.

The search strategy for this study starts with determining synonyms, which are part of the logic grid. Keywords used depend on the elements that have been used to develop the PICO review question (Aromataris & Riitano, 2014). Simple terms, such patients, nurses, hand hygiene, hospital acquired infections and hand washing, form the initial components of the search. By looking at the abstracts and titles of the articles that were retrieved, it was possible to find the key terms that were used in the literature, and key concepts that were important for the research question. During the comprehensive search, as many relevant key terms as possible were entered (Ho, Liew, Ng, Shunmugam & Glaszious, 2017). The utilization of the strategy in the research was aimed at determining whether some possibly relevant synonym could be overlooked as far as the question guiding the study was concerned since certain writers may have used different terms in relation to the concept.

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The second step involved the use of subject headings or index terms. Performing a comprehensive search requires the utilization of not only the keywords but also the various index terms while reviewing the existing articles. PubMed was reviewed based on its utilization MeSH terms as well as MEDLINE’s controlled-vocabulary. To determine the relevance of index terms to the ideas that were identified in the review question, each of the terms was sought in the MeSH database, which was selected from the drop list found on the PubMed home page. Moreover, a simple search using some of the key concepts or terms was conducted in the PubMed so as to discover index terms that may help in the retrieval of articles in order to see their indexing with the use of controlled vocabulary (Aromataris & Riitano, 2014). After obtaining results, the citations were scrolled through and titles of eligible articles clicked upon to view related details. Afterwards, the links to the MeSH terms of the articles were followed and examined according to their contents. Besides, the search techniques also encompassed the use of Boolean operators as well as filters. Boolean operators such as “AND” and “OR” became critical components of the search. For examples, “nurses” AND “hand washing”, “hand hygiene” OR “hand sterilizer”, “hand washing” AND “nosocomial infection”.

Literature Search Parameters

Initial Logic Grid Based on the PICO Elements Used in the Search

Population Intervention Comparison Outcome measures
Patients Handwashing education No handwashing education Reduced rate of hospital-acquired infections

Logic Grid Having Additional Keywords Used During the Search

Population Intervention Comparison Outcome Articles found
Patients Handwashing with soap No handwashing education Reduced rate of hospital-acquired infections (HAIs) 21
Intensive care unit patients Hand hygiene Nosocomial infections 4
Patients Use of alcohol-based products HAIs 6
Hand antisepsis HAIs 3
Hand disinfection Hospital-acquired infections 4
Surgical scrubs Hospital-acquired infections 2

The search yielded 39 articles containing relevant information that was required to answer the practice question. However, these articles were further filtered only according to the list of articles that were published from 2012 to 2017 to be included in the study. The articles included were considered more relevant because they provided the most relevant data and also met the requirement of being primary research. In the end, 5 articles were selected for this review.

Levels of Evidence-based on the JHNEBP Tool

Level Experimental Design
Level I Experimental studies: Randomized controlled trial (RCT), Systematic reviews of RCTs
Level II Quasi-experimental designs (QEDs), systematic reviews of mixed studies of RCTs and QEDs, or quasi-experimental studies only.
Level III Non-experimental studies: Qualitative studies as well as meta-synthesis
Level IV Opinions of trusted authorities, as well as consensus panels
Level V Literature reviews, quality evaluations, case reports, as well as expert opinions on experimental evidence

Source: (Dearholt & Dang, 2012)

These levels are important because they portray various strengths of evidence, which help decide whether to accept the recommendations from the evidence-based practice or not. As a result, stronger scientific evidence has more weight and is relied upon to make a decision.

Appraisal of Articles

Haverstick, S., Freeman, R., James, S., Kullar, R., & Ahrens, M. (2017). Patients’ hand washing and reducing hospital-acquired infection. Critical Care Nurse, 37(3), e1-e8.

This article reports a study that was conducted on the background that hand hygiene is critical in the prevention of hospital acquired infections. The article is appropriate because it gives an accurate description of the study. The study has an abstract, which provides a critical review of all the sections covered in the research. The abstract is important because it enables the reader to get an idea of what to look for while reading the article. In the introduction, the authors have argued that hand hygiene is important for hospital workers. The problem is that hospital acquired infections continue to be a major concern in many health centers. The objective of the study was to determine whether hand hygiene could be promoted through education on the issue of washing hands with soap and water or using hand sanitizer to minimize HAIs. Research question and theoretical framework, however, are not provided.

The authors focus on assessing whether the rates of infection by methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and Clostridium difficile bacteria reduced due to the education on hand hygiene. The patients involved in the study were those from the intensive care unit (ICU). This category of patients was suitable for the study because they were the ones who could not easily get to the sink to wash their hands after going through the postanesthesia care with chest tubes, ventricular assistive devices, nasogastric tubes, jejunostomy tubes, intravenous fluids or epidurals, or after taking the medications. Therefore, there was a need for the patients to ensure hand hygiene to protect themselves from nosocomial infections. The given quasi-experimental study provided level II evidence.

The study involved the collection of pretest data and post-test intervention data which formed the basis for further conclusions and recommendations. Nurses provided hand hygiene education to every patient who later answered the survey questions before and after the intervention. The quantitative analysis from the study was conducted with the use of SPSS with a significance level of 0.05. In the discussions, the researchers showed that there were notable correlations between hand hygiene and the rates of infection contamination with vancomycin resistant enterococci and meth-resistant Staph aureus with the rates of both declining after the intervention. Undoubtedly, level II evidence is of high value meaning that its results are reasonably consistent and the study sample size is sufficient for the study design chosen. Furthermore, there is certain level of control and the conclusion for the study is definitive. Besides, the recommendations were given following a thorough review of literature from scientifically-drawn evidences. The conclusion included the idea that education on the increased compliance with hand hygiene protocols resulted in decreased infection rates. The study also identified some of the limitations that may affect its applicability, including the research being conducted in a small unit, which minimizes the generalizability, as well as the research being performed in a busy unit, which may affect the applicability of the outcome, and potentially biased responses. The article provides well-grounded evidence, which makes it suitable for the current study.

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Fox, C., Wavra, T., Drake, D. A., Mulligan, D., Bennett, Y. P., Nelson, C…. & Bader, M. K. (2015). Use of patient hand hygiene protocol to reduce hospital-acquired infections and improve nurses’ hand washing. American Journal of Critical Care, 24(3), 216-224.

The title gives an accurate description of the article since it provides the summary of the study. The article begins with an abstract that provides an important overview of the study from the introduction and objective to the methodology used, data analysis, outcome, and conclusion. Importantly, registered nurses who work as the main care providers assume that hygiene can play a significant role in the prevention and reduction of HAIs among critically ill patients. The article also contains an introduction that helps to understand the purpose of the study. The problem statement helps to understand that severely ill patients are at an elevated risk of being infected with HAIs that are associated with increased likelihood of morbidity and mortality. This study has a clearly stated objective which determines a hand hygiene protocol for reducing HAIs rate and improving compliance with hand washing among nurses in an ICU. There is neither the research question nor the theoretical framework, which seem unnecessary for this study. The researchers used a pre-experimental research design with a posttest only comparison group that was conducted in this study. Similarly, the article provides a level II evidence based study design which is known as a research of high level according to Dearholt & Dang (2012). The study is of good quality because its results are reasonably consistent having been collected from a single intensive care unit of a hospital.

The sample size for this study is sufficient for the design because the researchers have reported that before the intervention, the number of patients involved was 2183 while during the implementation of the protocol, the number of participants reached 2326 with representatives in both cases coming from different wards, namely cardiac, medical and surgical. Therefore, it would be appropriate to say that the outcome of the study can be generalized. However, there was no control in this study. The method of statistical data analysis used was appropriate for quantitative data. In particular, the researchers used SPSS for the analysis of quantitative data. The significance level set at 99.95% ensured that there was no chance for any error in the calculations. Therefore, the results of the analysis were reliable and depicted a true picture of what would happen if the intervention was to be implemented after the trial. The conclusion for this study is fairly definitive with reduced rates of HAIs reported following the implementation of the proposed patient hand hygiene procedure as well as after meeting the hand washing requirements. Besides, the recommendations were composed after comprehensively reviewing the available literature based on certain relevant pieces of scientific evidence. The recommendations in this study are consistent with the literature review findings making them appropriate. It is also important to note that the researchers have indicated certain limitations that could affect the application of the outcomes of the investigation.

First, the researchers have acknowledged that the results of the protocol were compared with pre-intervention results (an untrue experiment) rather than a randomized control group (RCG), which makes it a true experiment and therefore limits the confidence in the outcome of the protocol. Similarly, there was no evaluation of physician training as well as catheter insertion. Besides, nurses were aware that they were being observed which could have resulted in higher than normal rates of washing hands, thus not giving a true picture of what could have happened if the nurses were not being observed. Finally, the researchers indicated that their study had been conducted in one health institution only; therefore, it may be inappropriate to generalize the results in regard to other units or health institutions. Undoubtedly, the article contains information that makes it appropriate for the current review.

Asadollahi, M., Bostanabad, M. A., Jebraili, M., Mahallei, M., Rasooli, A. S., & Abdolalipour, M. (2015). Nurses’ knowledge regarding hand hygiene and its individual and organizational predictors. Journal of Caring Sciences, 4(1), 45-53.

The article accurately describes the contents. The abstract provides an incisive overview of the areas that were covered in the research. There is no doubt that the information provided in the abstract contributed to choosing the article after it was found relevant and applicable for the current review. The introduction highlights the purpose of the article. In the introduction, there is an indication that 1.4 million people suffer from complications that are associated with hospital acquired infections. In the developing world, the rates of preventable HAIs associated with medical care are higher than 40% or more.

The problem is that HAIs remains a major challenge in ICU of many hospitals because patients in such units may lack awareness and be deprived of preventive mechanisms. Besides, preterm infants in neonatal units are at an increased risk of infection contamination and mortality because of immature immune systems. Therefore, nurses as health care professionals who play an important role in patient care must be aware of the essential role of hand hygiene. The study targeted an objective which was to determine the awareness of hand hygiene as well as its predictors among nurses working in the neonatal unit. There is neither a research question, nor a theoretical framework, both of which seemed unnecessary. This is a good quality research whose outline is consistent with those of similar studies. The study design is descriptive and cross-sectional providing level I evidence because of being experimental. Besides, the sample size of 150 nurses is sufficient for the study. Nonetheless, the study does not have control with which the study sample could be compared. The resulting data has been analyzed using SPSS with a confidence level of 99.95% meaning the results obtained were very accurate. Moreover, the discussion section has provided an insight into the findings and their implications, which is critical for making conclusions.

The conclusion in the given research is definitive because the researchers have highlighted the critical role of hand hygiene when it comes to controlling infections. Recommendations regarding the increase of knowledge on hand hygiene among nurses through education and the need to improve attitude of patients towards safety are consistent and based on reference from a literature review with scientific evidence. Lastly, the researchers were able to identify the limitations, which could be overcome in future studies to make outcomes more applicable. The article is applicable for the review question that has been developed for the given analysis. The evidence found in the article makes it suitable for the current review.

Mukerji, A., Narciso, J., Moore, C., McGeer, A., Kelly, E., & Shah, V. (2013). An observational study of the hand hygiene initiative: A comparison of preintervention and postintervention outcomes. BMJ, 3:e003018: doi: 10.1136/bmjopen-2013-003018

There is an accurate title for the article that summarizes the contents. The abstract of this study provides an overview of the main areas of the research including the objectives, design, participants, interventions, outcome measures, results, and conclusions. Besides, the introduction contains a purpose of the study. In the introduction, the authors state the problem that HAIs affect between 5 and 10% of patients in hospitals in industrialized nations with rates being higher among neonates in ICU. The authors indicated that their objective was to assess the effect of implementing an e-learning component on hand hygiene compliance as well as infection rates.

The study used a pre-intervention and post-intervention observational study design. The design is quasi-experimental meaning that it provides level II evidence. The given study had a sample size of 3422 participants, which stands for an adequate representation. However, there was no control group which can be considered a potential weakness of the study. A study group is important in any research because it forms the basis on which a comparison can be made to determine whether there is a positive, negative or no change after the intervention. The resulting data has been analyzed quantitatively with a high level of accuracy; as a result, it would be appropriate to say that the analysis was accurate. A thorough and relevant literature review has been provided to reinforce the study objectives, methodology used and results obtained.

The conclusion is definitive because it recognizes that even though it is not easy to achieve hand hygiene compliance among healthcare providers, the practical application of this goal still remains critical. The authors further conclude that their study complements the literature, which shows that a single one-time intervention can only have a minimum effect in reinforcing hand hygiene compliance. Besides, the recommendations given are consistent with the existing literature and provide the foundation for future studies that would lead to the development of creative and innovative ways of improving hand hygiene compliance. Finally, the study has identified various weaknesses that can be dealt with to make the study more effective. The existing weaknesses include lack of a control group, possible Hawthorne effect, limited audit, and lack of inclusion. The article is applicable for the PICO question. It contains information that makes it appropriate for the current review.

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Santosaningsih, D., Erikawati, D., Santoso, S., Noorhamdani, N., Ratridewi, I., Candradikusuma, D…. & Severin, J. A. (2017). Intervening with healthcare workers’ hand hygiene compliance, knowledge, and perception in a limited-resource hospital in Indonesia: A randomized controlled trial study. Antimicrobial Resistance and Infection Control, 6(23), DOI 10.1186/s13756-017-0179-y

The title accurately describes and summarizes the contents of the article making it appropriate for the review. The title also identifies what the researchers sought to determine and the method that was used to determine it. The abstract provided shows that the study was conducted on the background that hand hygiene (HH) is crucial for the prevention of HAIs. The introduction clearly defines the purpose of the article by stating that the adherence by healthcare works is based on their knowledge as well as perceptions. However, the problem is that the rates at which healthcare providers comply with hand hygiene, their level of knowledge, as well as the way they perceive different matters constitute a big challenge especially where the resources are not sufficient. Therefore, the objective of the study was to assess the way of how educational programs affect HH knowledge, compliance with, as well as perception of hygiene among healthcare workers. A study objective is important because at the end of the study, the researcher should be able to determine whether the goals targeted in the study have been achieved or not. The study lacks the research question and theoretical framework which were not very necessary.

The researchers have used a RCT with pre-intervention and post-intervention strategies. The given study design, therefore, provides level I evidence. The 2766 study participants that were involved in the study provided a sufficient sample size for evaluation. Importantly, the study had a control group against which the results of the experimental group could be compared to determine whether there were any or no changes after the application of the intervention. The conclusion in this study is definitive because the authors have stated that role model training is an important strategy that can be used to influence the awareness and perception of hand hygiene as well as hospital acquired infections, and help to improve compliance with the limited resources in hospitals. The recommendations given are consistent and based on a comprehensive review that is offered as scientific evidence. Notably, the researchers recommend that a multi-modal hand hygiene strategy needs to be re-customized according to the available resources and educational needs. Besides, the authors have identified various limitations of their study which could be improved in future researches to make the outcomes more applicable. The analyzed article is relevant for the current review based on the evidence provided in it.

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