Evidence-Based Practice


Nameof author


Introduction Theemergence of multi-drug resistant organisms (MDRO) is increasinglyrecognized as a threat to the public health (CDC, 2013). Many studiesrelated to the MDRO control strategy consider hand hygiene as animportant measure to reduce the burden of health care-associatedinfections. Reports from World Health Organization state thatthousands of people die every day around the world from infectionsacquired while receiving health care. Meanwhile, hands are the mainpathways of germ transmission during medical services. Hands are thehighways to the transmission and spread of bacteria, pathogens, andviruses that cause diseases, food-borne illness, and infectionsresulting from hospital treatment (nosocomial).

Infectiousgerms stick on the hands which are the most common medium for diseasetransfer. Sicknesses are caused by rubbing the nose or eyes withhands which have been contaminated with the cold virus and otherbacteria. Numerous studies support that hand washing reduces both thecarriage of pathogens on the hands and nosocomial infections (Steere&amp Mallison, 1975 Cooper, Medley, &amp Scott, 1999 Rotter,1999). Therefore hand hygiene is an important method of avoiding thetransmission of harmful germs and prevent health care-associatedinfections. So any health-care worker, caregiver or person involvedin direct or indirect patient care, needs to be concerned about handhygiene and should do it correctly and at the right time (WHO, 2009).

Adequatehand washing has resulted in significant reductions in the rates ofinfectious disease across a variety of setting such as health careinstitutions, the food industry, child day care centers, schools, andall community and domestic situations (Huang, Ma and

Stack,2012). Up to date, there are numerous studies which focus on topicssuch as hand-washing techniques, selection and handling ofhand-washing agents, and how to improve hygiene adherence amonghealth care workers (Haas and Larson, 2007).

Itis evident that the role of maintaining a healthy society falls notonly on the hands of medical professionals but also on the hands ofmany individuals in the community (Richardson, Wilson, Nishikawa, &ampHayward, 1995). All the societal institutions must be willing to worktogether for the better good. The health practitioners use theevidence-based practices and engage with these groups andorganizations to assist in improving the societal health. Theevidence-based practices help the healthcare providers to understandbetter the needs of the various segments of the society and devicethe best techniques to tackle their problems. For instance, thehealth workers can coordinate with the detergent manufacturers todevelop or formularize more efficient soaps that can eliminate theskin germs.

Thehealthcare providers coordinate with other societal bodies and healthinstitutions such as the World Health Organization to craft andimplement educational programs that enlighten the society members onthe importance and the techniques of maintaining adequate handhygiene. Through these programs, the community members get to learnthe consequences of not following the health guidelines as well asthe various types of diseases that they are likely to suffer once thepathogens enter into their body systems (World Health Organization,2009). Many experts in the infection control and preventiondepartments maintain that keeping clean hands is efficient andnecessary if at all reduced cases of infections are to be witnessedin the society and across health care settings. Other organizationsdealing with patients’ safety and quality provision including theJoint Commission and Institute for Healthcare Improvement haveconducted studies on the efficient techniques of applyingevidence-based methods towards tackling health issues.

Evidence-basedpractices would ensure that the medical professionals can put intopractice the theories proposed in several kinds of the literature ofpromoting health in the society. They would ensure that the nursingpractitioners can identify the applicability of the proposedtechniques because some theoretical aspects or ideas only exist inideal situations and not in real life. It is recommended that nursesshould coordinate with the Interprofessional teams that aim atimproving the provision of healthcare and medical facility resourceswhile applying the new competencies and the evidence-based practice(WorldHealth Organization, 2009).An article on strict hygiene compliance program indicates that handhygiene helps to diminish the risk of spending on health care oracquiring infections. In turn, improved hygiene leads to reducedmortality rates, reducing possibilities of disease colonization amongthe health professionals, and low levels of transfer of infection topatients.


Accordingto the hand hygiene guideline from World Health Organization, thecompliance of hand hygiene among health care workers helps to reduceinfection rate within the healthcare setting. To improve thefrequency of conformity of hand hygiene among healthcare workers andto reduce the acquisition of healthcare-associated infection, twoquestions are formulated by using the PICOT tool. The PICOT formatallows researchers to breakdown clinical questions into searchablekeywords as suggested by Richardson et al., 1995. Ideally, questionsare the driving force behind evidence-based practice (Eldredge,2000). Evidence-based practice (EBP) questions allow the researcherto focus on practical, real-world problems meaning that the urgentissues need to be placed in the context of EBP.

1stquestion: Intervention question

Theimprovement of hand hygiene compliance among healthcare workers helpsto prevent the acquisition of healthcare-associated infection. Howdoes the hand hygiene promotion program compared to the standardinfection control measure affect the rate of healthcare-associatedinfection?


Thepopulation of interest is health care workers as they are susceptibleto health care associated infections which lead to excess health carecosts and deaths. Of particular concern are patients admitted to theintensive care unit and surgical unit at the facility chosen for thestudy.


Theconcept being considered to address hand hygiene promotion programfocuses on improving compliance with HAI practice guidelines whichwere monitored based on surveillance.

C– Comparison

Thestrategy applied was aimed at identifying standard precaution ofinfection control measures for the local health facility as depictedin the study by Bruce (2013). The infection control measure sought tocollect surveillance and monitoring data to measure levels ofcompliance with transmission-based isolation practices.


Theoutcomes are represented by the rate of health care-associatedinfections. The study by Bruce (2013) sought to measure results basedon compliance with HAI prevention guidelines as well the reduction ofthe facility`s current HAI acquisition rates per the organization`sestablished surveillance program.


Thestudy by Bruce (2013) took about four weeks. For this study, the timeframe facilitated the project manager to meet the required projectsubmission deadlines.

2ndquestion: Meaning question

Howdo the healthcare workers who receive hand hygiene promotion programperceive hand hygiene to be significant in preventinghealthcare-associated infection?


Thepeople under consideration are health care workers who were drawnfrom an institution where the hand hygiene campaign had a ten-yearhistory. The other health care workers were in a local facility wherethey underwent inspection control in an attempt to measure theircompliance with hand hygiene promotion initiatives.


Theintervention is hand hygiene promotion program


Thecomparison intervention seeks to identify perceptions and attitudestowards hand hygiene. Research indicates that attitudes andbehavioral beliefs affect hand hygiene practices. The behavioralaspect covers motivation which determines compliance with suchcampaigns. Behavioral beliefs can thereby be used to determineresponse or adoption of hand hygiene programs.


Thedesired result is to prevent healthcare-associated infections.Perceptions and attitudes affect engagement in hand hygiene-relatedpractices as indicated in the studies conducted. The findingsregarding the attitudes and perceptions for the two studies show thatbehavioral beliefs and attitudes have the potential of affecting handhygiene compliance positively or negatively.

LiteratureSearch Study

Thesearch processes began from early-April until the last searchconducted at the end of May 2016. All the journals and articles wereobtained by the use of searching engines such as PubMed and the eKGsystem of Hospital Authority of Hong Kong. Journals and articlespublished after 2000 were included. Keywords for the searchingprocess were:

&quotHandhygiene&quot or &quothand washing&quot or &quotclean hands&quot,&quotcompliance&quot or &quotadherence&quot, &quotpractice&quotor &quotattitude&quot or &quotbeliefs&quot or &quotperceptions&quot,&quothealthcare workers&quot or &quotphysicians&quot or &quotnurses&quotor &quothealthcare providers&quot, &quotprogram&quot or&quotpromotion.&quot

Sincethere are numerous researches and studies related to hand hygiene, itis necessary to screen the abstract of the publications beforereviewing the full text. All articles with irrelevant informationwere excluded, while those which matched the inclusion criteriaproceeded to the reviewing of the full text.

Atthe beginning of the searching process, I acquired a total number of30 journals and articles 21 quantitative studies and ninequalitative studies included. These results were obtained after asearch of the keywords and combinations mentioned above. After thescreening process, only 16 journals and articles (13 quantitativestudies and three qualitative studies) complied with the inclusioncriteria. The inclusion criterion for the search was meant to locaatethe articles or journals conducted within the healthcare setting orfacilities. The target group or the population of the study is healthcare workers. The search considered compliance rate of hand hygieneamong healthcare worker which should be the impact or result of thepre and post assessment with the intervention or program involved.The relevant articles were those who used direct observation orinterview and those published since 2000 till now. Several studies orjournals were excluded due to several reasons including those whichprovided only hand hygiene compliance rates without any intervention only abstracts are given those which focused on the healthcareassociated infection rate instead of the rate of conformity of handhygiene.

Theultimate stage of the search involved the selection of two types ofresearch. The selection criteria used considered those articles thatwere concerned with the promotion of hand hygiene as one of theresearch objectives, the studies involving the perceptions andattitudes of the health care professionals and their effects on theobservation of hand hygiene practices. The other search criteria werebased on the studies that explored the adoption of HAIs. The initialsearch results yielded a total of seven different research works.Based on my elimination criteria, I was able to choose two lastanalysis pieces based on qualitative and quantitative research.According to Myers (2008) using various techniques for a researchenhances thorough understanding of the subject under analysis andaids to expand the research. The choice of the two types of researchwas based on the need for conducting a comprehensive research.

Appraisalof research articles

Thissection involves the critical analysis of the data evaluationtechniques. A critical analysis of literature titled “BasedPractice Formulating the Evidence Question: Frameworks Review Davies(2011)


BruceN. (2013) Improving compliance with healthcare-associated infectionpractice guideline reduce the acquisition of healthcare-associatedinfections. Doctor of Nursing Practice (DNP)

CapstoneProjects. Paper 30.

Appraisaltool: performance appraisal

Objective:Improving compliance with Healthcare Associated Infection (HAI)practice guidelines to reduce the acquisition of HAIs.

Thisarticle highlights the measures that can be applied to improveoverall compliance with guidelines designed to reduce health careassociated infections by people engaged in health care. Throughcompliance, it is evident that the rates of acquisition andtransmission are controllable. It improves the quality of life of thepatient as well as ensuring a healthy workforce (nurses and medicalstaff) capable of delivering the assigned tasks and duties. The mainweakness of the article is the lack of a substantive sample. It isbelow 100 which limits the data accuracy. Furthermore, as the studyprogressed, participation continued to diminish. The time frame waslimiting in the sense that it took four weeks. Proper monitoring forpost-intervention would require about six months.

Theresearch appraisal covers the sample, measurement methods, datacollection, data analysis, and the findings.


Conveniencesampling was used to arrive at a sample of 30 respondents drawn fromthe nursing and support staff within the facility. The choice ofconvenience sampling was based on the fact that the researcher soughtto collect data from a particular population hence making the samplerestrictions as the respondents were those positioned within themedical-surgical and the intensive care unit. For staff members toqualify as subjects of the sample they were required to be working inthe surgical and the intensive care unit and participation wasvoluntary. The improvement project was available to all staff memberswilling to participate. Each of the respondents was eligible forinclusion based on several factors: team members were employed by theorganization, on-site at a minimum one day per week, and provideddirect patient care.

ii)Measurement Methods

Theanalysis methods adopted for the study assessed the level ofcompliance with the HAI prevention guidelines as well as thereduction of the organization`s HAI acquisition rates based on thesurveillance program in place. For the facility in question, measuresobtained included the following: MDROs, Ventilator AcquiredPneumonias (VAP), Primary Blood Stream Infections (PBSI), andCatheter-Associated Urinary Tract Infections (CAUTI)). Specifically,the data measured the number of infections/device days x 1000 forPBSI and CAUTIs, the number of infections/ventilator days x 1000 forVAPs and the number of infections/patient days x 1000 for MDROs.

iii)Data collection

Datacollection was done through the use of tools like questionnaire,survey, HAI Surveillance and Monitoring tool. The Theory of PlannedBehavior Questionnaire was used to assess the participating staff aswell as the survey through Survey Monkey. It sought to identifyattitudes regarding the practice, beliefs relating to HAI preventionstrategies and adherence to HAI practice guidelines. Thequestionnaires have several advantages including the fact that theyare easy to administer code and summarize results as well as the factthat they are simple in design. The survey presents are easilyadministered on a large sample and can be used to obtain asignificant amount of information owing to the coverage of thesample.

Iv) Ethical Guidelines

Ethicalguidelines adhered to the respect of the identity of the respondents.The project did not collect any personal identifiers. A letterauthorizing the research was signed by the Chief Nurse Executive ofthe facility signifying the code of conduct. The results of the datawere described in aggregate figures. Ethical guidelines call for theneed to allow respondents to participate willingly in the researchand this particular research respondents were allowed to withdraw orparticipate voluntarily in the research. No evidence of coercion orforced engagement in the study is indicated.

v)Data Analysis

Dataanalysis was based on the review of HAI rates for 2012 which were thebenchmark goals established for comparison. HAI acquisition data wascollected to identify trends and levels of performance of theorganization. The results of the questionnaire were cleaned and codedto represent the responses from the sample subjects. Furthermore,measurements of infection were obtained from the project manager todetermine the acquisition and infection rates for comparisons.


Thestudy was relevant in highlighting the factors that influence theobservation of HAI precautions and the use of personal protectiveequipment during health services procedures. The results are usefulfor analyzing the performance of the health institution againstvarious standards. However, the lack of a convenient sample shedsdoubt on the accuracy of the findings. The study concluded that thecases of HAIs had reduced and this aspect is further indicated by thezero infection and colonization rate during the post-interventionperiod.


Qualitative:Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, PernegerTV. (2004) Hand hygiene among practitioners: performance, beliefs,and perceptions. Ann Intern Med 141:1-8.

Appraisaltool: performance appraisal

Thefindings of the research are important in determining physicians`perceptions and attitudes towards hand hygiene programs and practices(Ho, Seto, Wong, Wong, 2012). They influence the adoption of thesepractices which consequently determines the levels of the risk factorof the cross transmissions. The sample was representative therebyeliminating any form of bias and improving the generalizability ofthe findings to the population in question. The weaknesses includethe fact that the questionnaire or data collection tool was aself-reported questionnaire which presented challenges to therespondents especially if they needed clarifications. Theself-administered questionnaire lacks a personal touch and does notcapture non-verbal gestures which could be useful in the study.

Objective:To find out the factors leading to low adherence rate of hand hygieneamong the physicians such as their beliefs and perceptions on handhygiene practice.


Thestudy used a sample of 163 physicians at University of GenevaHospital, Switzerland. The design was a cross-sectional study andused the direct observation of the opportunities for the hand hygienein association with three levels of risk for cross-transmissionduring patient contact. They included the high degree of risk, themedium risk of the cross-transmission and the small risk ofcross-transmission. Afterward, the study used a self-administeredquestionnaire, given immediately after patients made contact tocollect the data about the cognitive factors related to hand hygienepractice.

ii)Measurement Methods

Thestudy sought to measure and document the risk of cross-transmissionthrough the direct observation of individual physicians. Theself-administered questionnaire was used to measure the physician`sbeliefs and perception associated with hand hygiene.

iii)Data collection

Datagathering was done through direct observation and a self-reportedquestionnaire. The disadvantage of this option is that in the eventof seeking clarifications about respondents encountering ambiguities,it’s hard to provide explanations for the responses provided asthey are based on their best knowledge. The advantage of using aquestionnaire is with respect to time saving because it is a toolthat can be administered to a large sample and can efficientlycollect relevant data over a short period (Gordin, Schulz, Huber, &ampGill, 2005). The questionnaire is applicable for a broadcross-section such as the sample under study. This tool is easy tosummarize and interpret during analysis.

iv) Data analysis

Dataanalysis was based on ranking, responses, and percentages. It waslarge because the replies were described using frequencies. The ratesdo not require sophisticated statistical tests to interpret. For thisreason, the data analysis representation was adequate and wassufficient to show the levels of agreement and disagreement based onthe factors investigated.

iv) Findings

Thestudy was crucial in realizing the various weaknesses that need to beaddressed by the health professionals to achieve compliance with handhygiene standards in the institutions (Fendler, Hammond, Lyons,Kelley, Vowell, 2002). The analysis identifies individual perceptionsof hand hygiene practices including behavioral beliefs, which favorhand hygiene, adherence based on peer pressure, training in the needfor hand hygiene, exposure to the hand hygiene campaign and femalesex, which increased the likelihood of compliance.


Thefindings from both kinds of literature prove to be relevant to myarea of professional practice. The two papers have indicated that theHAIs are highly susceptible to caregivers as well as patients.Furthermore, the studies have suggested that where invasiveprocedures are used, the risk of acquisition also increases, hencethe need to comply with regulations to safeguard against possibleinfections. Also, the two analyses have shown that HAIs can adverselyaffect the recovery of the patients, negatively influence the qualityof life and result in more costs associated with treatment. Patientsafety must be observed, and there is the need for preventing healthassociated infections in cases where they are avoidable (Mayer,Mooney, Gundlapalli, Harbarth, Stoddard et al. 2011). For thisreason, a critical observation of appropriate hand hygiene practicesis necessary to reduce the possibility of occurrence of HAIs.


Thefirst step of the implementation plan is the program model. In ourcase, the model concerns the application of the hand-hygieneinitiative as well as the HAI provisions for adequate health careprovision (Davies, 2011). The aim of the program is to reduce thenumber of infections resulting from health-based services. This modelis useful for application in various health departments andinstitutions. The main facilitators of this initiative are the healthprofessionals from different sectors and organizations. To make theplan work efficiently, there is the need to ensure that the recruitedstaffs have the necessary skills which are enhanced through trainingeither in seminars or field practice. The other initiative towards aneffective implementation plan is the client acquisition and retentionprocedures. Effective communication of the importance of the programis essential for the extensive use of the program. The ultimate stepwould involve the collection and evaluation of data, which wouldassist to evaluate the effectiveness of the project.


Thestudy by Bruce (2013) proves that observing the health hygieneguidelines could potentially reduce HAI infection rates. A consciouseffort to adhere to these requirements can potentially reduce theacquisition and transmission of such diseases (Ryan, Christian, &ampWohlrabe, 2001). Violation of such guidelines increases thepossibility of infection. More so, identifying perceptions thataffect hand hygiene practices is important. It is because theyindicate what drives health care workers to behave in a particularmanner.

Thegoal of improvement programs and other forms of intervention towardsthe reduction of HAIs is to preserve the health of caregivers andimprove the recovery of patients while providing a quality standardof attention (Eldredge, 2000). These studies are in line with otherfindings which indicate that nurses and healthcare workers believethat hand hygiene practice implementation is significantly correlatedwith evidence-based practice. A mentor can create strong beliefs,execution of duties and group cohesion. Despite the limitations ofthe study design, the findings show that the EBP program comprises ofskills building activities and intensive workshops that have positiveeffects on the health workers perception, beliefs and implementation(Chen, Sheng, Wang, Chang, Lin et al. 2011). However, there is agreat need to replicate these studies in other areas because thedifference in organizational structures, service delivery models, andeducational systems may influence results. Replication of thisstrategy in other settings and areas of an organization which isaffected by this culture is important in establishing if the ARCCmentorship and findings of the model hold across organizationalcultures and international settings (Bruce, 2013).


BruceN. (2013) Improving compliance with healthcare associated infectionpractice guideline reduce the acquisition of healthcare-associatedinfections. Doctor of Nursing Practice (DNP) Capstone Projects.Paper 30.

ChenY.C.,ShengW.H.,WangJ.T.,ChangS.C.,LinH.C.,et al.(2011)Effectiveness and limitations of hand hygiene promotion ondecreasing healthcareassociatedinfections. PLoSONE 20116(11):e27163.

Davies,K. (2011). Formulating the Evidence Based Practice Question: A Reviewof the Frameworks. Evidence Based Library and Information Practice,6 (2), 75-80.

Eldredge,J. D. (2000). Evidence-based librarianship: An overview. Bulletin ofthe Medical Library Association, 88(4), 289-302.

Fendler, Ali,. Y, Hammond, B.S, Lyons MK, Kelley,. M.B., Vowell, N.A.(2002). The impact of alcohol hand sanitizer use on infection ratesin an extended care facility. Am J Infect Control 30(4): 226-233.

Gordin,F.M. , Schulz. M.E., Huber, R.A. &amp Gill, J.A. (2005) Reduction innosocomial transmission of drug resistant bacteria afterintroduction of an alcohol-based hand rub. Infect Cont HospEpidemiol 26(7): 650-653.

HoM.L.,SetoW.H.,WongL.C., WongT.Y. (2012).Effectiveness of multifaceted hand hygiene interventions inlong-term care facilities in Hong Kong: A cluster-randomizedcontrolled trial. InfectControl Hosp Epidemiol33(8):761-767.

MayerJ.,MooneyB.,GundlapalliA.,HarbarthS.,StoddardG.J.,et al.(2011).Dissemination and sustainability of a hospital-wide hand hygieneprogram emphasizing positive reinforcement. InfectControl Hosp Epidemiol32(1):59-66.

Myers,M.D. (2008). Overview of Qualitative Research. In: Frenz, M., NielsenK. &amp Walters, G. ed. (2011). Research Methods in Management.London: SAGE Publications Ltd. pp. 87- 98.

Pittet,D. , Hugonnet, S. , Harbarth, S., Mourouga, P., Sauvan, V., &ampTouveneau, S. (2000). Effectiveness of a hospital wide programme toimprove compliance with hand hygiene. Lancet 2000 356: 1307-1312.

PittetD, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV.(2004) Hand hygiene among physicians: performance, beliefs, andperceptions. Ann Intern Med 141:1-8.

Richardson,W. S., Wilson, M. C., Nishikawa, J., &amp Hayward, R. S. A. (1995).The well-built clinical question: A key to evidence-baseddecisions. ACP Journal Club, 123, A12-13.

Ryan,M., Christian, R.S., &amp Wohlrabe J. (2001). Handwashing andrespiratory illness among young adults in military training. Am JPrev Med 21(2): 79-83.

SaxH., Uckay I., Richet H., Allegranzi B. and Pittet D. Madeo M. (2007)Determinants of Good Adherence to Hand Hygiene Among HealthcareAmong Healthcare Workers Who Have Extensive Exposure to Hand HygieneCampaigns. Infection Control and Hospital Epidemiology. Vol 28:11,pp 1267-1274

TrickW.E.,VernonM.O.,WelbelS.F.,DeMaraisP.,HaydenM.K.,et al.(2007).Multicenter intervention program to increase adherence to handhygiene recommendations and glove use and to reduce the incidence ofantimicrobial resistance. InfectControl Hosp Epidemiol28:42-49.

WorldHealth Organization (2009). WHO guidelines on hand hygiene in healthcare. First global patient safety challenge: clean care is safecare.http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf[Accessed31 May 2016].