Hospital-acquired diseases are related to adverse health outcomes, which increases health care expenses, hospitalization period, and preventable laboratory examinations. Hand hygiene is considered to be a key part of reducing these diseases because of its cost-effectiveness and ease of adoption. Improving hand hygiene compliance can lead to the reduction of hospital-acquired infections and other challenges such as antimicrobial resistance. The primary issue, however, is the low compliance levels among health care workers, particularly nurses who are at the forefront of providing care. It is, therefore, important to find ways of improving compliance to hand hygiene protocols among DNP leaders.
The current DNP project reviews the literature for studies that focus on interventions to improve hand hygiene compliance. The project starts with the formulation of a PICOT question literature evaluation to determine the type of evidence, evidence levels, and evidence quality of the identified studies. The literature review will focus on peer-reviewed and recent articles published within the last five years.
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PICOT: in DNA leaders (P), how does a multifaceted approach (I) compared to existing practice (C) influence hand hygiene compliance (O) during hospitalization (T)?
Table of Evidence for four articles
Article King, D., Vlaev, I., Everett-Thomas, R., Fitzpatrick, M., Darzi, A., & Birnbach, D. J. (2016). “Priming” Hand Hygiene Compliance in Clinical Environments. Health Psychology , 35 (1), 96–101. https://doi.org/10.1037/hea0000239 Sadule-Rios, N., & Aguilera, G. (2017). Nurses’ Perceptions of Reasons for Persistent Low Rates in Hand Hygiene Compliance. Intensive and Critical Care Nursing , 42 , 17–21. https://doi.org/10.1016/j.iccn.2017.02.005 . Sands, M., & Aunger, R. (2020). Determinants of Hand Hygiene Compliance Among Nurses in US Hospitals: A Formative Research Study. PLOS ONE , 15 (4), e0230573. https://doi.org/10.1371/journal.pone.0230573 Saharman, Y. R., Aoulad Fares, D., El-Atmani, S., Sedono, R., Aditianingsih, D., Karuniawati, A., van Rosmalen, J., Verbrugh, H. A., & Severin, J. A. (2019). A multifaceted hand hygiene improvement program on the intensive care units of the National Referral Hospital of Indonesia in Jakarta. Antimicrobial Resistance and Infection Control , 8 , 93. https://doi.org/10.1186/s13756-019-0540-4 | Author & Date King et al., 2016 Sadule-Rios & Aguilera, 2017 Sands & Aunger, 2020 Saharman et al., 2019 | Evidence Type RCT Exploratory, descriptive survey Behavior-centered mixed research Observational, prospective, before-and-after | Sample, Sample Size, Setting 400 mix of service users and health care professionals in a surgical intensive care unit at a Miami teaching hospital 47 nurses at Magnet hospital with 452 beds 540 acute care nurses in different geographically distributed hospitals across the United States 97 intensive health care workers at a 1200 bed sized Dr. Cipto Mangunkusumo Hospital, Jakarta. |
Priming influenced compliance to hand hygiene protocols Understaffing and high workload makes it difficult to access hand hygiene resources, which reduces compliance. Compliance to hand hygiene protocols relied on communication openness among the management, reduced stress, workload, and cognitive workload; and increased interactions with staff members and patients. A multifaceted improvement program for healthcare workers in larger hospitals leads to significant improvements of knowledge in hand hygiene and improvement in compliance to hand hygiene protocols. | Limitations The study did not ask the participant why they did not engage in hand hygiene. The study also randomized the interventions by days, which may have different mixes of visitors in the SICU. The study did not mention the percentage of observed visitors vs. hospital staff Included surveys from a single hospital. Only critical care nurses were included from one hospital. Study occurred during system wide changes at the study facility. The use of self-report surveys can be flawed. The use of online data recruitment may have limited generalizability. The use of direct observations limited continuous monitoring. Presence of Hawthorne effect and observation bias. | Evidence Level & Quality Level I, Good quality. Level I, Good quality. Level I, Good quality. Level I, Good quality. |
Summary/Evaluation
Article 1
King, D., Vlaev, I., Everett-Thomas, R., Fitzpatrick, M., Darzi, A., & Birnbach, D. J. (2016). “Priming” Hand Hygiene Compliance in Clinical Environments. Health Psychology , 35 (1), 96–101. https://doi.org/10.1037/hea0000239
Summary
The study was based on a randomized controlled trial that occurred in an intensive care unit. It included 404 participants entering the surgical intensive care unit at a Miami teaching hospital, Florida. The participants were made up of healthcare workers including ancillary staff, nurses, and physicians besides hospital visitors. The study occurred over three months starting from November 2012 to January 2013. It sought to investigate the potential contribution of priming on hand hygiene compliance in a real clinical setting. The study used priming by focusing on two interventions, olfactory prime and visual prime. During the olfactory prime intervention, researchers exposed the ICU visitors to a citrus smell that they introduced into the room using a commercial aroma dispenser. Each exposure session lasted a minimum of 24 hours. For visual prime, researchers exposed visitors of the ICU to an image of the eye that they displayed prominently above a gel dispenser.
Researchers used a set of female eyes in half of the session and a set of male eyes for the other half session. Two observers sat at a discreet location and had a clear view of the study area without being identified by the participants. The main data measured entailed coding each instance as either did not wash hands or washed hands. They used a random number generator to randomize each intervention category. The recorded data relied on gender including male and female and intervention including scent, no scent, male eyes, and female eyes. Coding occurred for each session and intervention. Researchers analyzed the collected data by dividing the interventions into three binary variables of yes or no and performed a logistic regression to examine if each coefficient significantly differed from zero. Gender was used as a covariate when conducting the logistic regression analysis. There are, however, issues with validity and reliability of observations. Observing the occurrence of behaviors repeatedly consumes time. The study outcomes may not reflect a large population, which means it cannot be generalized to the entire hospital population. Researchers’ bias may have also influenced the data collected
The final results demonstrated reliable evidence that olfactory priming enhanced compliance to hand hygiene protocols. King (2015) states that the findings of the study suggested that priming can be used to influence compliance to hand hygiene protocols in clinical settings. The implication is that priming can be used to change behaviors related to public health.
Evidence (Appendix A)
The RCT included health care workers and hospital visitors in one intensive care unit. The sample size was fairly large, and the findings were consistent and reliable. Even though the participants became aware of the scent and signs, the researchers did not disclose whether or not the respondents were aware of the objective of the study. It was also possible that the observers might have seen the signs and scents. Additionally, it was unclear in the study if the staff moved between units or within the unit. While the study faced a high risk of detection bias, it fully exploited non-comparability between groups as the data analysis prevented the bias through the impact of treatment allocation. The study also had reasonably consistent outcomes, adequate number of well-designed studies, and a definitive conclusion. The article will contribute to the development of the project by providing background information about ways to improve compliance to hand hygiene protocols.
Article 2
Sadule-Rios, N., & Aguilera, G. (2017). Nurses’ Perceptions of Reasons for Persistent Low Rates in Hand Hygiene Compliance. Intensive and Critical Care Nursing , 42 , 17–21. https://doi.org/10.1016/j.iccn.2017.02.005
Summary
The study sought to investigate the perception of nurses regarding the reasons for low rates of compliance to hand hygiene protocols. Researchers used an exploratory and descriptive survey methodology in determining the perceptions of critical care nurses regarding the barriers to hand hygiene compliance. The study focused on answering two research questions, which included what were the perceptions of nurses regarding the reasons for a persistent low rating in compliance to hand hygiene in the critical care unit? And what were the suggestions of nurses to improve compliance to hand hygiene in the critical care unit? The study occurred at Magnet hospital, which had a capacity of 452 beds. It included a convenience sample of critical care nurses who worked 12 hours night or day shift. The research occurred over one month. The study used questionnaires to collect data. The researchers obtained the questionnaire from a review of the literature that determined the noticeable challenges concerning the absence of compliance to hand hygiene protocols in health care environments. The challenges included attitudinal beliefs and environmental barriers. The questionnaire had 18 items that assessed barriers to compliance to hand hygiene among critical care unit nurses and two-open-ended questions that allowed nurses to describe the main challenge they viewed as a barrier to compliance and their recommendations for improvement.
The survey was conducted one time as the researchers did not have any contact with the participants after the completion of the first survey. The validity and reliability of the survey relied on the consistency of the responses and the type of questions that the researchers asked. Consistent responses would lead to high reliability but wrong questions would lead to low validity. The use of descriptive statistics, however, to examine the statistical features of the questionnaire by analyzing the attributes of each item increased both the validity and reliability of the survey. The researchers used the SPSS version 23.0 to analyze the responses from the items in the questionnaire. The frequency of responses and word repetition were used to analyze open-ended-questions. The researchers found that understaffing and high workload hindered nurses in the critical care unit from accessing hand hygiene resources. The authors suggested that interventions such as dealing with nursing workload and understaffing besides modifying the environment to enable easy access to hand sanitizers and sinks can enhance the compliance of nurses to hand hygiene protocols in the critical care unit.
Evidence (Appendix A)
The sample size was small, but the use of a survey and statistical analysis increased the reliability of the evidence. While the study had a small sample size and the design restricted the number of questions that could be asked, it used both qualitative and quantitative methods in the collection and analysis of data. In turn, this helped the researchers to offer a wider picture of the issue through identifying generalizations and trends and deep understanding of the perspectives of the participants. The only challenges concerned the potential for the researchers to have been over-involved, which can lead to bias of the outcomes. The study will be used to offer information about the barriers that prevent the abilities of nurses to engage in safe daily hand hygiene practices. The source also provides additional information about the potential of modifying the environment to help nurses to quickly adapt to hand hygiene practices.
Article 3
Saharman, Y. R., Aoulad Fares, D., El-Atmani, S., Sedono, R., Aditianingsih, D., Karuniawati, A., van Rosmalen, J., Verbrugh, H. A., & Severin, J. A. (2019). A multifaceted hand hygiene improvement program on the intensive care units of the National Referral Hospital of Indonesia in Jakarta. Antimicrobial Resistance and Infection Control , 8 , 93. https://doi.org/10.1186/s13756-019-0540-4
Summary
The researchers conducted an observational prospective study within two intensive care units at the Dr. Cipto Mangunkusumo Hospital, which had a capacity of 1200 beds. The study sought to develop a multifaceted hand hygiene improvement plan to be used in the hospital. The study occurred in four stages in which the baseline or first stage entailed the use of anonymous observations followed by the use of a questionnaire to conduct hand hygiene knowledge tests. The second stage entailed the application of intervention, which included implementing a multifaceted improvement program consisting of role models, interviews, reminders, feedback, and education. The third stage involved post-intervention in which the researchers conducted knowledge tests through questionnaires again and used observations to measure hand hygiene compliance. The last stage entailed assessing hand hygiene compliance. The study participants included 8 physicians and 43 nurses from the general ICU and 6 physicians, 34 nurses, and 6 student nurses from the ER-ICU. One physician and two nurses participated in the hand hygiene improvement programs but did not participate in questionnaires, interviews, and observations.
The researchers used an intervention focused on reminders, feedback, and education. Education occurred through interactive lessons including written material, practical demonstrations, and formal lectures. The researchers offered tailored and non-tailored performance feedback to participants during stage 2 and 3. They also offered reminders through hand washing message posters located in visible areas in the ICUs. The research also involved seven group interviews to identify the significance of social influence. The investigators also used the Hand Hygiene knowledge questionnaire that had 8 questions with 17 sub-questions regarding knowledge, perceived obstacles, attitude, and self-reported behavior. Direct observations were used to monitor hand hygiene compliance.
The use of a mixed research method involving questionnaires, interviews, and observations to gather data from different sources including nurses and physicians from different ICU unites increased the reliability and validity of the data. Additionally, the researchers offered a detailed explanation regarding the way they collected and analyzed the data and the way they derived different themes and the results, which contributed to the reliability and validity of the measurement tools.
The study used the Mann-Whitney test for independent samples to analyze the knowledge questions. The technique was used to calculate and compare the mean and median scores of each participant. They also used Fisher’s exact testing to analyze the effect of the intervention on correct answers of each question regarding knowledge while the Wilcoxon signed-rank test was applied in comparing the distribution of the correctly answered questions before and after the intervention. Linear mixed models were used to determine the effects of the improvement program on compliance. A kappa statistic was used to analyze the concordance between the observers. Statistical analyses involved the use of SPSS version 22. The multifaceted hand hygiene improvement program for physicians and nurses greatly enhanced hand hygiene compliance and hand hygiene knowledge. Continuous monitoring and regular interventions are needed to ensure high hand hygiene compliance rates over time.
Evidence (Appendix A)
A fairly large sample size, the use of interviews, questionnaires, and observations besides the application of statistical analysis increased the consistency and reliability of the results. The study used existing data sets and collected extra desired data. The design allowed the researchers to better assess the impact of the intervention using comprehensive data with long term follow up. The use of blinding and the assessment of the intervention in different ICUs allowed the researchers to explore a wider range of relevant outcomes and specify uniform data collection techniques and uniform definitions both for exposure and outcome. The study will be used to provide suggestions for improving hand hygiene compliance among nurses.
Article 4
Sands, M., & Aunger, R. (2020). Determinants of Hand Hygiene Compliance Among Nurses in US Hospitals: A Formative Research Study. PLOS ONE , 15 (4), e0230573. https://doi.org/10.1371/journal.pone.0230573
Summary
The researchers used a behavior centered design (BCD) to determine the factors that affect hand hygiene compliance of intensive and acute care unit nurses. The sampling procedure entailed administering an online cross-sectional survey to a group of nurse participants working in different geographic regions across the United States. The participants included 540 hospital nurses across various geographically distributed hospitals. The researchers used a survey to examine the potential factors that determined hand hygiene compliance, which included norms, behavior setting stage, roles, habit, and motivation. The study used professional identity to examine the role of nurses. The study also adapted previously designed questions focused on measuring the normative system of nursing concerning hand hygiene behavior before presenting the results using a Likert scale. The self-report habit index was used to measure the strengths of nurses’ hand hygiene habits.
The researchers also used the BCD motive mapping to determine factors that motivated nurses to practice hand hygiene. The survey focused on measuring the level of the various factors that affected the reported hand hygiene compliance. The researchers developed a questionnaire using the self-reported habit index and vignettes. The study used vignettes to identify the degree to which different situational constraints affected hand hygiene behavior. Researchers used a five-point Likert scale based on the potential for behavioral response to present the responses from the vignettes. Researchers also elicited open-ended responses by using photos to seek recommendations from the participants during investigations regarding the different ways of disrupting a behavior setting. The study also measured the safety culture of the hospitals of the participants using a modified hospital survey on patient safety culture before presenting the results using a five-point Likert scale.
The survey allowed the researchers to capture detailed data on various domains of behavior. The use of photos together with open-ended questions allowed the participants to describe the specific behaviors that influenced their hand hygiene behavior. The online administration of the survey enabled the use of skip logic that allowed participants to follow tailored paths through the questionnaire by skipping inappropriate questions. In turn, this increased efficiency, reduced participant burden, eradicated missing information and enabled participants to control their time. The online administration also allowed the researchers to gather data from a wide distribution of nurses, which enhanced the validity and reliability of the study. There were several limitations, however, which included that the survey could only reach nurses who had internet access and were familiar with computers. The survey may have only reflected responses from participants with a high educational level and socioeconomic status. Additionally, the researchers may have found it challenging to calculate response rates because they could only determine data on participants without additional information regarding the number of potential participants who accessed the survey but failed to participate.
The investigators used descriptive statistics to characterize the sample by conducting univariate analysis to identify the variables related to reported hand hygiene compliance levels. The study also used multivariate regression of the identified variables on the norm, safety culture, role, and demographic variables. The study findings showed that HHC had a high likelihood of being a function of cognitive load related to role performance, reduced stress and workload, high interaction levels with staff and patients, perceived peer performance, and the transparency of the hospital management.
The authors suggested that a potential intervention to enhance hand hygiene compliance among nurses should focus on enhancing transparency in communications, the effect of peer perceived performance, increasing interactions between nurses and staff and patients, and identify ways to decrease the cognitive load and stress related to role performance.
Evidence (Appendix A)
The BCD technique allowed the researchers to include a broader range of factors encompassing both macro-sociological and psychological in a single model. The study clearly outlined the set of events that are required to enhance hand hygiene compliance. The design also ensured consistency of the embedded model through a step-by-step process. The study will be used to provide recommendations regarding the different ways to improve compliance to hand hygiene protocols.
References
King, D., Vlaev, I., Everett-Thomas, R., Fitzpatrick, M., Darzi, A., & Birnbach, D. J. (2016). “Priming” Hand Hygiene Compliance in Clinical Environments. Health Psychology , 35 (1), 96–101. https://doi.org/10.1037/hea0000239
Sadule-Rios, N., & Aguilera, G. (2017). Nurses’ Perceptions of Reasons for Persistent Low Rates in Hand Hygiene Compliance. Intensive and Critical Care Nursing , 42 , 17–21. https://doi.org/10.1016/j.iccn.2017.02.005
Saharman, Y. R., Aoulad Fares, D., El-Atmani, S., Sedono, R., Aditianingsih, D., Karuniawati, A., van Rosmalen, J., Verbrugh, H. A., & Severin, J. A. (2019). A Multifaceted Hand Hygiene Improvement Program on the Intensive Care Units of the National Referral Hospital of Indonesia in Jakarta. Antimicrobial Resistance and Infection Control , 8 , 93. https://doi.org/10.1186/s13756-019-0540-4
Sands, M., & Aunger, R. (2020). Determinants of Hand Hygiene Compliance Among Nurses in US Hospitals: A Formative Research Study. PLOS ONE , 15 (4), e0230573. https://doi.org/10.1371/journal.pone.0230573
Appendix A: Article Appraisal
AGREE II Score Sheet
King et al., 2016
| Domain | Item | AGREE II Rating |
| Scope and purpose | The overall objective(s) of the guideline is (are) specifically described. The health question(s) covered by the guideline is (are) specifically described The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described. | 7 7 7 |
| Stakeholder involvement | The guideline development group includes individuals from all the relevant professional groups. The views and preferences of the target population (patients, public, etc.) have been sought. The target users of the guideline are clearly defined. | 7 3 6 |
| Rigor of development | Systematic methods were used to search for evidence. The criteria for selecting the evidence are clearly described. The strengths and limitations of the body of evidence are clearly described. The methods for formulating the recommendations are clearly described. The health benefits, side effects and risks have been considered in formulating the recommendations. There is an explicit link between the recommendations and the supporting evidence. The guideline has been externally reviewed by experts prior to its publication. A procedure for updating the guideline is provided. | 4 7 7 4 4 7 7 2 |
| Clarity of presentation | The recommendations are specific and unambiguous. The different options for management of the condition or health issue are clearly presented. Key recommendations are easily identifiable. | 5 5 4 |
| Applicability | The guideline describes facilitators and barriers to its application. The guideline provides advice and/or tools on how the recommendations can be put into practice. The potential resource implications of applying the recommendations have been considered. The guideline presents monitoring and/ or auditing criteria. | 4 3 4 1 |
| Editorial independence | The views of the funding body have not influenced the content of the guideline. Competing interests of guideline development group members have been recorded and addressed. | 3 3 |
| Overall Guideline Assessment | Rate the overall quality of this guideline. | 6 |
| Overall Guideline Assessment | I would recommend this guideline for use. | Yes, with modifications |
Sadule-Rios & Aguilera, 2017
| Domain | Item | AGREE II Rating |
| Scope and purpose | The overall objective(s) of the guideline is (are) specifically described. The health question(s) covered by the guideline is (are) specifically described The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described. | 7 7 7 |
| Stakeholder involvement | The guideline development group includes individuals from all the relevant professional groups. The views and preferences of the target population (patients, public, etc.) have been sought. The target users of the guideline are clearly defined. | 7 6 7 |
| Rigor of development | Systematic methods were used to search for evidence. The criteria for selecting the evidence are clearly described. The strengths and limitations of the body of evidence are clearly described. The methods for formulating the recommendations are clearly described. The health benefits, side effects and risks have been considered in formulating the recommendations. There is an explicit link between the recommendations and the supporting evidence. The guideline has been externally reviewed by experts prior to its publication. A procedure for updating the guideline is provided. | 5 7 7 6 3 7 7 3 |
| Clarity of presentation | The recommendations are specific and unambiguous. The different options for management of the condition or health issue are clearly presented. Key recommendations are easily identifiable. | 7 6 7 |
| Applicability | The guideline describes facilitators and barriers to its application. The guideline provides advice and/or tools on how the recommendations can be put into practice. The potential resource implications of applying the recommendations have been considered. The guideline presents monitoring and/ or auditing criteria. | 3 7 4 1 |
| Editorial independence | The views of the funding body have not influenced the content of the guideline. Competing interests of guideline development group members have been recorded and addressed. | 3 3 |
| Overall Guideline Assessment | Rate the overall quality of this guideline. | 6 |
| Overall Guideline Assessment | I would recommend this guideline for use. | Yes, with modifications |
Saharman et al., 2019
| Domain | Item | AGREE II Rating |
| Scope and purpose | The overall objective(s) of the guideline is (are) specifically described. The health question(s) covered by the guideline is (are) specifically described The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described. | 7 4 7 |
| Stakeholder involvement | The guideline development group includes individuals from all the relevant professional groups. The views and preferences of the target population (patients, public, etc.) have been sought. The target users of the guideline are clearly defined. | 7 7 7 |
| Rigor of development | Systematic methods were used to search for evidence. The criteria for selecting the evidence are clearly described. The strengths and limitations of the body of evidence are clearly described. The methods for formulating the recommendations are clearly described. The health benefits, side effects and risks have been considered in formulating the recommendations. There is an explicit link between the recommendations and the supporting evidence. The guideline has been externally reviewed by experts prior to its publication. A procedure for updating the guideline is provided. | 7 7 7 3 3 7 7 2 |
| Clarity of presentation | The recommendations are specific and unambiguous. The different options for management of the condition or health issue are clearly presented. Key recommendations are easily identifiable. | 7 7 7 |
| Applicability | The guideline describes facilitators and barriers to its application. The guideline provides advice and/or tools on how the recommendations can be put into practice. The potential resource implications of applying the recommendations have been considered. The guideline presents monitoring and/ or auditing criteria. | 5 3 4 2 |
| Editorial independence | The views of the funding body have not influenced the content of the guideline. Competing interests of guideline development group members have been recorded and addressed. | 7 4 |
| Overall Guideline Assessment | Rate the overall quality of this guideline. | 6 |
| Overall Guideline Assessment | I would recommend this guideline for use. | Yes, with modifications |
Sands & Aunger, 2020
| Domain | Item | AGREE II Rating |
| Scope and purpose | The overall objective(s) of the guideline is (are) specifically described. The health question(s) covered by the guideline is (are) specifically described The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described. | 7 7 7 |
| Stakeholder involvement | The guideline development group includes individuals from all the relevant professional groups. The views and preferences of the target population (patients, public, etc.) have been sought. The target users of the guideline are clearly defined. | 7 7 7 |
| Rigor of development | Systematic methods were used to search for evidence. The criteria for selecting the evidence are clearly described. The strengths and limitations of the body of evidence are clearly described. The methods for formulating the recommendations are clearly described. The health benefits, side effects and risks have been considered in formulating the recommendations. There is an explicit link between the recommendations and the supporting evidence. The guideline has been externally reviewed by experts prior to its publication. A procedure for updating the guideline is provided. | 7 7 7 4 5 7 7 2 |
| Clarity of presentation | The recommendations are specific and unambiguous. The different options for management of the condition or health issue are clearly presented. Key recommendations are easily identifiable. | 7 7 7 |
| Applicability | The guideline describes facilitators and barriers to its application. The guideline provides advice and/or tools on how the recommendations can be put into practice. The potential resource implications of applying the recommendations have been considered. The guideline presents monitoring and/ or auditing criteria. | 4 3 4 1 |
| Editorial independence | The views of the funding body have not influenced the content of the guideline. Competing interests of guideline development group members have been recorded and addressed. | 4 3 |
| Overall Guideline Assessment | Rate the overall quality of this guideline. | 6 |
| Overall Guideline Assessment | I would recommend this guideline for use. | Yes, with modifications |
The rating ranges from 1 to 7 with 1 indicating the strongest disagreement and 7 indicating the strongest agreement. The overall guideline assessment was based on a rating that ranged from 1 to 7 with 1 indicaating the lowest quality and 7 indicating the highest quality.
