Order Description
THIS IS ASSESSMENT 3.IT HAS PARTS A AND B
THIS WHOLE ASSESSMENT IS A CONTINUATION OF ASSESSMENT 1 AND 2.I HAVE PASTED ASSESSMENT 1 AND 2 AT THE BOTTOM OF THE ASSESSMENT 3 DESCRIPTION SO THAT U CAN FOLLOW.ALSO INCLUDED IS THE RUBRIC
ASSESSMENT FOR ASSESSMENT 3.

MY CLINICAL AUDIT QUESTION FROM ASSESSMENT 1 AND 2 HAS BEEN===DO NURSES IN AN ACUTE CARE SETTING IN XXX HOSPITAL PRACTICE BEST PRACTICE HAND HYGIENE?.
PART 3A AND 3B QUESTIONS.
Required Length:
Part A: 1,500-word written report Value 35%
Part B: 5 minute multimedia or digital presentation Value 10%

Part A: Written report that describes your proposed clinical audit and how you would implement it in order to measure compliance with your best practice standard audit indicators.
Include:
A paragraph on clinical governance as it applies to your place of work and ensure you identify where the clinical audit process fits within the clinical governance structure.
Identify the clinical audit process you have chosen to apply; is it a five step, seven or twelve step process and is it an audit-intervention-reaudit model or something else. Do not explain all
the steps of your chosen model, this is a waste of words and you do not have that many. Only explain the steps in the audit process that relate to this assignment and the marking rubric will help
with this.
Ensure you explain in some depth your ‘sample’, the ‘data to be collected’, how you will ‘analysis’ the data and report it to your colleagues/ authorities and how you will obtain ‘ethical’ approval
and guard against ethical issues. The marking rubric will give you an indication as to how much you need to write in these sections.
Finally, complete the JBI Clinical Audit Plan Template sections of on audit indicators for ‘structure’, ‘process’ and ‘outcome’ and also the next section that requires you to list each item of
structure, process and outcome identifying what ‘audit activity’ you will undertake to obtain clinical practice data on that point that will enable you to then measure compliance with best
practice. NOTE: Identifying all the items of structure, process and outcome for each of your clinical audit indicators and then identifying what audit activities you will undertake to obtain data
on each is a substantial task, what I request is that you complete this for one or two of your audit indicators and not everyone. It will be a sample that will demonstrate to me you know how to do
this if you were to complete it for every one of your audit indicators.
Appendices: Attach your JBI Clinical Audit Template Plan and any other information you feel is relevant.
Use the assessment rubric to help structure your assignment both in terms of heading sections and the amount to write based on the marks allocated that section.
Tip: The test of a quality clinical audit plan is that if a clinician was to read it they would be able to understand what is expected and be able implement it.

Part B: 5 minute multimedia or digital presentation that would be suitable to show colleagues that would be an overview of your plan for the conduct of a clinical audit.
Question: What would be an example of the content expected in such a presentation?
Answer: Just imagine you have only 5 minutes or so to catch your colleagues attention to tell them about your clinical audit topic, what evidence you found and the standard of best practice that
you have identified and then how the clinical audit could be implemented and the types of data to be collected to measure the degree to which current practice complies with best practice standard.
Question: What is an example of how I could do it?
Answer: You could film yourself on video talking to the clinical audit plan or you could use power point and record your comments to each of the slides? I would use no more than 3 slides in this
type of presentation. JUST USE A POWER POINT WITH COMMENTS ON IT.

Hint: Any of your colleagues viewing this presentation of the method or design should be able to tell you exactly how the audit will be conducteD
.
RUBRIC FOR ASSESSMENT3
PART A: AUDIT METHOD & DESIGN (80% of total mark)
INTRODUCTION (0 marks – hurdle requirement)
Introduction includes an overview of the content contained in the report, which enables the reader to know what is ahead, similar to a map.
QUALITY IMPROVEMENT FRAMEWORK (5% of total mark)

? Clearly describes the QA and Clinical Governance system in the workplace, & identifies where the clinical audit fits within this system to improve clinical practice. Explains how quality
improvement using clinical audit supports a consistent approach to best clinical practice. (5 marks)
? Describes the QA and Clinical Governance system in the workplace, & identifies where the clinical audit fits within this system to improve clinical practice.

(4 marks)
? Good attempt but has not offered sufficient detail about how the clinical audit fits within the Clinical Governance system of the organisation as a quality improvement strategy. Has missed a
number of key points that as a result show only a basic level of understanding about organisational system of Clinical Governance.

(3 marks)
? Poor or missing attempt at describing the QA and Clinical Governance system. Talked in general terms about Clinical Governance.

(<3 marks)

CLINICAL AUDIT PROCESS (15% of total mark)
? Clearly describes and explains the separate steps in the clinical audit process. The content would enable the reader to be fully informed on how to implement the clinical audit in their
workplace.
(13-15 marks)
? Describes and explains the separate steps in the clinical audit process and exacting information that show application of the concepts. The content would enable the reader to understand what
would be expected of them when implementing the clinical audit in their workplace (10-12 marks)
? Describes the separate steps in the clinical audit process and applies each to their clinical audit. The content would enable the reader to understand what was to be achieved but implementation
would necessitate more specific information.
(7-9 marks)
? Describes a clinical audit process but missing information that demonstrates a basic application of the concepts. The content offers the reader an overview of what is to be done if the clinical
audit was to be implemented but a lack of specific detail would hinder implementation

(5-7 marks)
? Poor or missing attempt at describing the separate steps in the clinical audit process. The content would not enable the reader to implement the clinical audit as planned
(<5 marks)

SAMPLE (10% of total mark)
? Comprehensive description of the makeup and numbers of the sample, including excellent rationale for decisions about sampling. (9-10 marks)
? Good description of the makeup and numbers of the sample, including rationale for decisions about sampling.

(7- 8 marks)
? Fair description of the makeup and numbers of the sample, with rationale for decisions about sampling.

(6-7 marks)
? Includes a description of the makeup and numbers of the sample, but misses the rationale for decisions about sampling.

(5-6 marks)
? Poor or missing attempt at explaining the sample for the audit.

(<5 marks)

DATA COLLECTION (20% of total mark)

? Explains clearly what data is to be collected and how it will be stored and used to assess compliance. The information offered matches that provided in more detail in the JBI template plan.
(17-20 marks)
? Explains what data is to be collected and how it will be stored and used to assess compliance. The information offered links to those expressed in the JBI template plan.

(14-16 marks)
? Explains what data is to be collected and how it will be stored and a good attempt at explaining how it will be used to assess compliance. The information offered is consistent with that listed
in the JBI template plan but association by inference is needed.

(12-13 marks)
? Good attempt at explaining what data is to be collected, misses some explanation of why some data and/or missing how it will be stored and used to assess compliance.

The information offered does not directly link to the JBI plan but is consistent with the content of the plan. (10-11 marks)
? Poor or missing attempt at explaining what data is to be collected and how it will be stored and used to assess compliance.

The information offered does not link to the JBI plan.
(<10 marks)

DATA ANALYSIS (5% of total mark)
? Clearly explains how date will be interpreted and used to assess compliance with best practice standards. (5 marks)
? Explains how date will be interpreted and used to assess compliance with best practice standards. (4 marks)
? Good attempt to explain how date will be interpreted. Fails to explain how it will be used to assess compliance with best practice standards.

(3 marks)
? Poor or missing attempt at explaining how data will be interpreted.

(<3 marks)

ETHICS (5% of total mark)
? Clearly outlines all ethical considerations & safeguards required to be met to conduct this project.

(5 marks)
? Clearly outlines most ethical considerations & safeguards required to be met to conduct this project.

(4 marks)
? Good attempt to outline some ethical considerations & safeguards required to be met to conduct this project, but misses some key items
(3 marks)
? Poor or missing attempt at outlining ethical considerations & safeguards required to conduct this project. (<3 marks)

CONCLUSION (0 marks – hurdle requirement)
A statement that brings together all the main elements of the plan. All items of evidence used in the report are referenced in accordance with the APA system of referencing.
TEMPLATE PLAN (20% of total mark)
? Builds on previous template plan to include all structure, processes and actions. (17- 20 marks)
? Builds on previous template plan to include all structure, processes and actions. (14-16 marks)
? Builds on previous template plan to include all structure, processes and actions. (12-13 marks)

? Good attempt to build on previous template plan but misses some key structures, processes or actions. (10-11 marks)

? Poor or missing attempt at describing template plan.
(<10 marks)
PART B: MULTIMEDIA / DIGITIAL PRESENTATION (20% of total mark)
CREATIVITY (20% of total mark)
? Presentation succinctly delivers an effective creative message, explaining the plan for a clinical audit.

(17-20 marks)
? Presentation delivers an effective creative message, explaining the plan for a clinical audit.

(14-16 marks)
? Good attempt at a presentation to explain the audit.
(12-13 marks)

? Fair attempt at a presentation to explain the audit, but misses key points or fails to deliver message effectively. (10-11 marks)

? Poor or missing attempt at a digital presentation.

(<10 marks)
SUBTOTAL

ASSESSMENT1-
Introduction
Failure to provide safe care within the guidelines stipulated by the National Health Service can lead to devastating outcomes to patients. According to Cherry et al. (2012), patient safety
continues to be a global concern today as shown by the development of the world health organization. While hand washing might not be as glamorous as the hi-tech interventions that have permeated
the healthcare sector, it nonetheless remains the single most important thing practitioners can do to avert the spread of diseases (Thoa, et al., 2015). Indeed, it is impossible to argue against
the fact that a safe working environment is a caring environment.

Yokoe et al. (2014) note that adhering to correct hand hygiene practices is essential to the reduction of the risks of associated healthcare infections. In as much as multimodal programs meant for
improving healthcare worker, hand hygiene adherence, has demonstrated effectiveness, their efficacy is limited and often hard to sustain. Thus, observance to hand hygiene guidelines in a great
number of healthcare facilities has not been followed to the letter. Failure of hand hygiene practices has been demonstrated by nurses in acute care setting in xx hospital, who continuously score
low in the monthly clinical audits. Thus raising a question of what could be the causative factors and how the problem could be solved. Realistically, acute care nurses tend to be bombarded with a
lot of activities which lead to heavy workloads and thus ignorance to hand hygiene in the process of meeting the work demands.
Background
Healthcare-associated infections (HAIs) continue to affect the results of healthcare in acute care environments given their related health challenges. Every year, over 2.6 million patients in the
US contract HAIs that lead to an estimated 90,000 deaths, costing the health care sector over $5 billion in health care costs (Goodliffe, et al., 2014). Nevertheless, despite the growing
surveillance for Healthcare-associated infections, evidence-based hand hygiene that curbs hand-to-hand or hand-to-skin infection stands out as the most effective means of reducing the risks of
contracting Healthcare-associated infections in an acute care setting (Dai, et al., 2015).

However, Yokoe et al. (2014) argue that most nurses continue to exhibit noncompliance to the guidelines of proper hand hygiene. It emerges that despite knowing the guidelines, most of them opt to
breach aseptic technique or misuse gloves as substitutes for hand hygiene. As such, it is important to determine the factors that hinder the acute care nurses in xx hospital from complying with
laid down safety guidelines with regards to hand hygiene. If the correct hand hygiene practices were followed, patients care would improve in terms of shortening their stay, better health outcomes,
decreased health costs and minimal burnout of acute care nurses. Most importantly there will be greater confidence in the entire health system hence a healthy community (Goodliffe et.al,2014).

According to CourtneyandMcCutcleon,2010, Patient Intervention Compliance and outcome (PICO) is a framework that helps to construct an answerable question that aids in searching for current evidence
based practises in the clinical settings. Thus PICO format was applied in the construction of the clinical audit question as illustrated in the table below.
Clinical audit question?
Do nurses in an acute care setting in xx hospital, experience factors that hinder them from adhering to the best hand hygiene practices while caring for the patients?
Problem /population The risk of Healthcare Associated Infections
By the acute care nurses.
Intervention Nurses utilize soap and water or antiseptic hand rubs in order to curb transmission of infections from one patient to another in an acute care setting.
Comparison Simple hand hygiene is a mandatory practice in an acute health care setting and all nurses are expected to be consistent and conscious of it while handling acute patients.
Outcome It is reasonable to expect that nurses in acute care setting comply with the best practice of hand hygiene while caring for the acutely ill patients.
Approach
De bru’n and Pierce-smith (2013) argue that, proper search strategies need to be employed in order to yield rich results of current evidence based practises. Thus this paper, adopted a systematic
review approach. Specifically, the paper searched the databases of Medline, CINAHL, and Embase, January 2011 up to December 2016. The paper limited itself to scholarships of human beings, with
language restricted to English, data below seven years, all acute care nurses whether newly employed or old and nurses on duty. The exclusion criteria included, Data over seven years, nurses on
leave or days off and community nurses. The adopted search terms include the operational filters of the EPOC coupled with designated MeSH terminology (evidence-based practice) besides free text
terms (hand washing and hand hygiene, acute care settings and nurses) as advocated by studies. The EPOC approach is a widely used data collection worksheet that incorporates research objectives,
settings, and design, coupled with a study’s target populace, outcomes measures, a sketch of the treatment, and the selected analysis approach and results. The inclusion criterion included studies
with at least an outcome comparison with a randomized control group
Results
The study’s initial search for published works from 2011 through 2016 and current studies resulted in 10,470 hits for all the consulted databases. However, only 623 publications met the inclusion
criteria. An assessment of the full text of the qualifying studies led to 590 more studies being excluded due to the lack of HH compliance outcomes or because they were not interventional. A
further appraisal and quality assessment lead to 28 studies being included for analysis while the remaining were omitted due to significant quality issues.

The studies appraised revealed interesting information regarding the compliance practices of nurses in acute care settings as summarized in the table.
Factor Frequency
Lack of knowledge 10 studies reported that nurses attributed failure to comply with hand hygiene due to the lack of awareness on the importance of the same
Lack of time 15 studies observed that most nurses lacked the time to properly scrub their hands as required by guidelines
Forgetfulness 20 studies reported that while some nurses are aware of the need to comply with hand wash they just forgot
Lack of means 7 studies noted that some facilities lacked the necessary resources required for proper hand washing measures.
Skin irritation 12 studies reported that some nurses feared that the chemicals used in washing their hands could lead to skin irritation.
Lack of training 15 studies indicated that some nurses lacked the necessary training on evidence-based hand hygiene practices
Conflict between the need to provide care and self-protection 20 studies noted that some nurses were torn between protecting themselves against elements such as dry skin and providing care to the
sick.
Distance to necessary and facility 8 studies claimed that the distance to the required hand wash facility demoralized the nurses
Uncomfortable equipment 5 studies cited awkward hand washing equipment as the barriers to proper hand hygiene practices among the nurses.
CONCLUSION
Using the best search strategy available, this paper has outlined the clinical audit question in a systematic way, highlighting the key factors that hinder the nurses in in xx hospital to comply
with the best standard in hand hygiene practices. These factors need to be taken into consideration by the whole health care system when taking the next step in putting these guidelines into
practice e.g. for the educators or nums to keep on updating the nurses on performance in their hand hygiene practices, also instructing new nurses on how to deliver the best care for patients in
regard to hand hygiene.

References
Cherry, M. G., Brown, J. M., Bethell, G. S., Neal, T., & Shaw, N. J. (2012). Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a
hospital care setting. A BEME systematic review: BEME Guide No. 22. Medical teacher, 34(6), e406-e420.
Courtney, M. D., & McCutcheon, H. (2010). Using Evidence to Guide Nursing Practice. Sydney: Churchill Livingstone.,
Pearce-Smith, N. D. B. C. (2013). Searching Skills Toolkit. : Wiley. Retrieved from https://www.ebrary.com.

Thoa, V. T. H., Van Trang, D. T., Tien, N. P., Van, D. T., Wertheim, H. F., & Son, N. T. (2015). Cost-effectiveness of a hand hygiene program on health care–associated infections in intensive care
patients at a tertiary care hospital in Vietnam. American journal of infection control, 43(12), e93-e99.
Yokoe, D. S., Anderson, D. J., Berenholtz, S. M., Calfee, D. P., Dubberke, E. R., Ellingson, K. D., … & Lo, E. (2014). A compendium of strategies to prevent healthcare-associated infections in
acute care hospitals: 2014 updates. American journal of infection control, 42(8), 820-828.
Dai, H., Milkman, K. L., Hofmann, D. A., & Staats, B. R. (2015). The impact of time at work and time off from work on rule compliance: The case of hand hygiene in health care. Journal of Applied
Psychology, 100(3), 846.
Goodliffe, L., Ragan, K., Larocque, M., Borgundvaag, E., Khan, S., Moore, C., & McGeer, A. J. (2014). Rate of Healthcare Worker–Patient Interaction and Hand Hygiene Opportunities in an Acute Care
Setting. Infection Control & Hospital Epidemiology, 35(03), 225-230.
Barnes, S. L., Morgan, D. J., Harris, A. D., Carling, P. C., & Thom, K. A. (2014). Preventing the transmission of multidrug-resistant organisms: modelling the relative importance of hand hygiene
and environmental cleaning interventions. Infection Control & Hospital Epidemiology, 35(09), 1156-1162.

ASSESSMENT 2

This paper has utilized the Joanna Briggs levels of evidence in critiquing the clinical audit question. Please find below the levels of evidence as illustrated in appendix A. In addition, presented
below in table 1 is: managing the evidence-an overview (after inclusion and exclusion criteria have been applied).
TABLE 1
Rating Evidence Number of studies.
Highest Level 1 10
Level 2 4
Level 3 3
Level 4 6
lowest Level 5 0
Ungraded items 2
total 22
Themes that emerged from the literature as examined below.
Lack of knowledge
Studies report that knowledge regarding hand hygiene compliance is linked with reduced levels of infection transmission in an acute care setting. For instance, one study observes that nurses with
good knowledge on hand hygiene are 3.8 times more likely to comply than those with poor awareness of the best hand hygiene practices. Another study by Nabavi et al. (2015) that studied nurses’
attitude and knowledge towards hand hygiene practices reported that the degree of knowledge about hand hygiene was moderate (65.7%) among the study’s 256 participants. Interestingly, the study
observed that 67% of the respondents had poor knowledge of hand hygiene, thus explaining the high incidences of infections. Nair (2014) hared similar results noting that even as the nurses had
better knowledge of the practice than medical students (p=.023), knowledge of evidence-based hand hygiene practices among nurses is still moderate (74%).
Distance to necessary facility
Alsubaie (2013) adopted an observational study design in five intensive care units with the objective of establishing the determinants of hand hygiene compliance among interns and observed that the
physical environment (distance between hand washing sink) determines the extent to which nurses comply with hand hygiene practices. Four focus groups employed by Efstathiou, et al. (2011) reported
similar findings noting that the stowage of hand hygiene equipment in locations far away from where care is needed contributes to noncompliance.
Lack of means
Studies revealed that while nurses were ready to comply with the necessary hand hygiene practices, the absence (Efstathiou, et al., 2011) or the shortage of proper protective equipment such as
gloves (Ahmed, 2011) also led to non-cooperation.
Skin irritation
The cross-sectional study among 100 nurses by Shinde & Mohite (2014) noted skin irritation as an occupational hazard faced by most nursing staff. The paper identified that most hand washing
detergents leave the skin either dry or irritated hence pushing some nurses to avoid maintaining proper hand hygiene practices. Sharma, Sharma & Koushal (2012), however, reasoned that the concept
of skin irritation is a myth that when properly conducted, hand hygiene leads to no skin irritation.
Conflict between the need to provide care and self-protection
Specifically, while the nurses were very much willing to maintain high standards of hygiene while providing care, conflicts such as earlier discussed skin irritation make it hard to comply.
Lack of training
Training teaches nurses the necessary knowledge required of the necessary hand hygiene practices. However, despite its importance, most nurses are either training used age-old training manuals that
do not take heed of modern evidence-based hand hygiene practices.
Uncomfortable equipment
Nurses need a conducive work environment for them to provide safe and quality care services. A conducive work environment, as explained by experts is characterized by several factors including
well-maintained and adequate equipment. Where nurses find the available equipment to be unfit, the possibility of their being non-compliance is high. Okhiai et al. (2014) non-experimental study
exposed that the height of hand washing sinks prevented some nurses from adhering to proper hand hygiene regimes.
Lack of time
One study reported that most nurses failed to practice effective hand hygiene practices because they are always occupied and that proper hand hygiene consumes up valuable time that could be devoted
to caring for patients.
Forgetfulness
Twenty studies reported forgetfulness as a major hindrance to compliance. Apparently, while most nurses were aware of the importance of maintaining high levels of hand hygiene during the provision
of care, the possibility of forgetting to do so is high especially during emergencies.

Levels of evidence and grades of recommendations.

Clinical audit question

Do nurses in an acute care setting in xx hospital comply with best practice hand hygiene?
Clinical bottom line

a. There is strong evidence to suggest that staffing should be sufficient to meet task requirements so that the nurses may not be too much in a hurry to ignore hand hygiene practices while carrying
out procedures. Zingg, W., Holmes, A., Dettenkofer, M., Goetting, T., Secci, F., Clack, L., … & Pittet, D. (2015) Level 1.
b. There is strong evidence to support the negligence of hand hygiene practices by acute care nurses due to location of hand hygiene apparatus away from the procedure site. Nabavi, M., Alavi-
Moghaddam, M., Gachkar, L., & Moeinian, M. (2015.) Level 4.
c. There is a strong evidence to suggest that the attitude of acute care nurses towards hand hygiene practices i.e. skin irritation, forgetfulness etc., leads to noncompliance with hand hygiene.
Luctkar-Flude, M., Baker, C., Hopkins-Rosseel, D., Pulling, C., McGraw, R., Medves, J., … & Brown, C. A. (2014.) Level 4.
d. There is a weak evidence to suggest that the student nurses in an acute care clinical placements had little knowledge about hand hygiene in regard to the five moments of hand wash Nair, S. S.,
Hanumantappa, R., Hiremath, S. G., Siraj, M. A., & Raghunath, P. (2014). Level 4.

Best practice recommendation.

Substantial evidence confirms that hand hygiene practices adopted by nurses affect clinical outcomes in acute care settings. Indeed, evidence shows that when proper hand hygiene regimes are
followed, infection rates reduce significantly. As such, nurse compliance with evidence-based hand hygiene practices in acute care settings are mandatory. However, the findings reveal that despite
being important, compliance rates are still moderate
.
The best practice recommendation will be utilized using the Joanna Briggs institute” Grades of recommendation “as illustrated in appendix c.

1. Hospitals should ensure adequate staffing to reduce cases of overload that might see nurses forgetting or feeling too tired to practice hand wash hygiene (Grade A)
2. The culture of hand hygiene should be passed on by the old acute care nurses to the newly employed or students in the clinical placements (Grade B).
3. There is some evidence showing that some acute care nurses may use gloves as a substitute of hand hygiene practices (Grade A).
4. There is a strong evidence to support monthly hand hygiene audits by the clinical nurse educators in order to illustrate the performance levels of hand hygiene in an acute care setting. (Grade
A.)
5. The acute care nurses should utilize hand hygiene practices as it is the single most effective way of infection -prevention in an acute setting (Grade A).
Conclusion.
This paper has critiqued a wide range of evidence which draws a clinical bottom line, that can be used to inform the current evidence based practice.
?
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Okhiai, O., Nwaopara, A. O., Omoregbe, F. I., Izefua, E., Nwandike, G. I., Nmorsi, P., … & Blackies, H. O. T. (2014). A study on knowledge, attitude and practice of standard precautions among
theatre personnel in Irrua Specialist Teaching Hospital, Irrua, Edo State. International Journal of Basic, Applied and Innovative Research, 3(4), 147-153.
Rejitha, I. M., Sucilathangam, G., & Revathy, C. (2016). Assessment of Knowledge, Attitude and Practice of Hand Washing Among Health Care Workers in a Tertiary Care Hospital. Global Journal For
Research Analysis, 4(8).
Sharif, A., Arbabisarjou, A., Balouchi, A., Ahmadidarrehsima, S., & Kashani, H. H. (2016). Knowledge, Attitude, and Performance of Nurses toward Hand Hygiene in Hospitals. Global journal of health
science, 8(8), 57.
Sharma, R., Sharma, M., & Koushal, V. (2012). Hand washing compliance among healthcare staff in Intensive Care Unit (ICU) of a Multispecialty Hospital of North India. Journal of hospital
Administration, 1(2), p27.
Shinde, M. B., & Mohite, V. R. (2014). A study to assess knowledge, attitude and practices of five moments of hand hygiene among nursing staff and students at a tertiary care hospital at Karad.
International Journal of Science and Research (IJSR), 3(2), 311-321.
Zingg, W., Holmes, A., Dettenkofer, M., Goetting, T., Secci, F., Clack, L., … & Pittet, D. (2015). Hospital organization, management, and structure for prevention of health-care-associated
infection: a systematic review and expert consensus. The Lancet Infectious Diseases, 15(2), 212-224.

Joanna Briggs Institute Grades of Recommendation
A “strong” recommendation for certain health management strategy where:
Grade A

1. it is clear that desirable effects outweigh undesirable effects of the strategy;
2. where there is evidence of adequate quality supporting its use;
3. there is benefit or no impact on resource use, and
4. values, preferences and the patient experience have been taken into account.
A “weak” recommendation for certain health management strategy where:
Grade B

1. desirable effects appear to outweigh undesirable effects of the strategy, although this is not as clear;
2. where there is evidence supporting its use, although this may not be of high quality;
3. there is a benefit, no impact or minimal impact on resource use, and
4. values, preferences and the patient experience may or may not have been taken into account.
Appendix D: Managing the Evidence
Level of evidence Type Studies
Level 1 Experimental Designs Zingg et al. (2015)
Level 2 Quasi-experimental design Erasmus et al. (2010a)
Level 3 Observational study Alsubaie (2015); Fuller et al. (2011): Bennett, et al. (2015)
Level 4 Observational descriptive studies Al-Wazzan et al. (2011); Cherry (2012); Nabavi et al. (2015); Nair et al. (2014)’ Kale et al. (2014); Shinde & Mohite (2014); Sharma et al. (2012); Okhiai,
et al. (2014); Asadollahi et al. (2015); Efstathiou et al. (2011); Cruz & Bashtawi (2016): Luctkar-Flude, et al. (2014); Shari, et al. (2016): Ariyarathne et al. (2013); Abaza, et al. (2010);
Hosseinialhashemi, et al. (2015); Maheshwari, V. (2014); Bello et al. (2013); Mu’taz, et al. (2016): AlSaleh, et al. (2016); Mahmood, S. E., Verma, R., & Khan, M. B. (2015
Level 5 Expert opinion and bench research None
Total 28

Appendix E: managing the evidence each item
Authors Method Findings Level of evidence
Ahmed, E. E. (2011)
Zingg, W., Holmes, A., Dettenkofer, M., Goetting, T., Secci, F., Clack, L., … & Pittet, D. (2015 A systematic review Hospital organization, management, and structure comprise manageable and
widely applicable ways to reduce health-care-associated infections and improve patients’ safety. Level 1
Erasmus, V., Brouwer, W., Van Beeck, E. F., Oenema, A., Daha, T. J., Richardus, J. H., … & Brug, J. (2010 A qualitative study based on structured-interview Nurses and medical students expressed
the importance of hand hygiene for preventing of cross-infection among patients and themselves Level 2
Nabavi, M., Alavi-Moghaddam, M., Gachkar, L., & Moeinian, M. (2015 A cross-sectional KAP study The mean overall score of the nurses’ knowledge was 14.2 ± 2.6 (mean ± SD). The residents received
weak scores in attitudes and practices. Additionally, none of the residents performed hand washing with available means (water and hand-washing liquid) in the morning visit hours. Level 4
Nair, S. S., Hanumantappa, R., Hiremath, S. G., Siraj, M. A., & Raghunath, P. (2014). A cross-sectional study Nursing students knowledge (= 0.023) , attitude (= 0.023), and practices ( < 0.05) were
significantly better than medical students. Level 4
Alsubaie, S., bin Maither, A., Alalmaei, W., Al-Shammari, A. D., Tashkandi, M., Somily, A. M., … & BinSaeed, A. A. (2013 Observational study design The overall observed noncompliance rate was
58%. The factors associated with noncompliance were HCW job title, working in a pediatric ICU, and performance of HH before patient contact. Level 2
Al-Wazzan, B., Salmeen, Y., Al-Amiri, E., Abul, A. A., Bouhaimed, M., & Al-Taiar, A. (2011). A cross-sectional study At 33.4%, the overall compliance was low. Nurses reported higher compliance
after conducting patient care activities rather than before. Being busy with work (42.2%), having sore/dry hands (30.4%) and wearing gloves (20. 3%) were the most frequently report ted hindrances
to improving hand hygiene. Level 4
Fuller, C., Savage, J., Besser, S., Hayward, A., Cookson, B., Cooper, B., & Stone, S. (2011). Observational study Gloves were used in 1,983 (26.2%) of the 7,578 moments for hand hygiene and in 551
(16.7%) of 3,292 low-risk contacts; gloves were not used in 141 (21.1%) of 669 high-risk contacts. The rate of hand hygiene compliance with glove use was 41.4% (415 of 1,002 moments), and the rate
without glove use was 50.0% (1,344 of 2,686 moments). Level 2
Cherry, M. G., Brown, J. M., Bethell, G. S., Neal, T., & Shaw, N. J. (2012) Systematic review Multiple, continuous interventions were better than single interventions in terms of eliciting and
sustaining behavior change Level 4
Kale, M., Gholap, M., & Shinde, M. (2014). Descriptive co relational design Majority (66%) of the student nurses had an average knowledge whereas 20% students showed a satisfactory performance of
universal precautions Level 4
Shinde, M. B., & Mohite, V. R. (2014). A cross-sectional study The knowledge on hand hygiene was moderate (144 out of 200, 74%) among the total study population. The majority of students had poor
attitudes with regard to hand hygiene. Nursing students had significantly (P < 0.05) better attitudes (52%) compared to nursing staff (12%) Level 4
Okhiai, O., Nwaopara, A. O., Omoregbe, F. I., Izefua, E., Nwandike, G. I., Nmorsi, P., … & Blackies, H. O. T. (2014). A study on knowledge, attitude and practice of standard precautions among
theatre personnel in Irrua Specialist Teaching Hospital, Irrua, Edo State Descriptive non-experimental study Eighty percent of the theater personnel had knowledge of standard precautions, while
83.3% had positive attitude towards it with 66.7% of the respondents complying with standard precautions. Level 4
Asadollahi, M., Bostanabad, M. A., Jebraili, M., Mahallei, M., Rasooli, A. S., & Abdolalipour, M. (2015). Descriptive cross-sectional study Most of participants have an acceptable level of
knowledge regarding hand hygiene. The highest score was for infection control domain and the lowest score was for definition of hand hygiene domain. Level 4
Efstathiou, G., Papastavrou, E., Raftopoulos, V., & Merkouris, A. (2011). A focus group study Factors that influence nurses’ compliance emerged. Most factors could be applied to one of the main
domains of the HBM: benefits, barriers, severity, susceptibility, cues to action, and self-efficacy. Level 4
Cruz, J. P., & Bashtawi, M. A. (2016) A cross-sectional self-reported study The majority displayed a moderate attitude toward hand hygiene (52.1%), while only a few reported a poor attitude
(13.1%). Approximately 68.7%, 29.8%, and 1.5% of the respondents reported moderate, good, and poor practice of hand hygiene, respectively. Level 4
Luctkar-Flude, M., Baker, C., Hopkins-Rosseel, D., Pulling, C., McGraw, R., Medves, J., … & Brown, C. A. (2014) Systematic review of descriptive studies Lack of knowledge, poor attitude, need to
evade skin irritation and forgetfulness were identified as the major deterrence to hand hygiene practices. Level 4
Sharif, A., Arbabisarjou, A., Balouchi, A., Ahmadidarrehsima, S., & Kashani, H. H. (2016). Cross sectional study The majority of nurses had good knowledge 149 (74.5%), positive attitude 141 (70.5%)
and good performance 175 (87.5%) towards hand hygiene. Level 4
Bennett, S. D., Otieno, R., Ayers, T. L., Odhiambo, A., Faith, S. H., & Quick, R. (2015). Observational study From baseline to follow-up, there was a statistically significant increase in the
percentage of dispensaries with access to HWSs with soap (42% vs. 77%, p<0.01) and access to safe drinking water (6% vs. 55%, p<0.01). Level 3
Rejitha, I. M., Sucilathangam, G., & Revathy, C. (2016) Cross sectional descriptive study Health care providers had reasonable knowledge about hand washing and the risk of nosocomial infections,
but suboptimal practices especially with hand-drying. Their attitude towards hand hygiene is also not appreciable. Level 4
Ariyarathne, M. H. J. D., Gunasekara, T. D. C. P., Weerasekara, M. M., Kottahachchi, J., Kudavidanage, B. P., & Fernando, S. S. N. (2013) Cross-sectional study Participants had moderate knowledge
(77%) but attitudes, practices and satisfaction of facilities of all the participants was overall poor (<50%). However the nursing students had better knowledge (p=0.023), attitudes (p<0.001),
practices (p<0.001) and satisfaction of facilities (p<0.001) compared with the medical students. Level 4
Abaza, A. F., Amine, A. E., & Hazzah, W. A. (2010). Cross sectional study Hand washing with nonantiseptic soap and water and all of the four used alcohol-based hand rubs showed significant
reduction of bacterial counts on the examined hands. Level 4
Hosseinialhashemi, M., Kermani, F. S., Palenik, C. J., Pourasghari, H., & Askarian, M. (2015) Cross sectional study Work experience had a correlation with practices and knowledge (P < .05), and
knowledge and practices scores were positively correlated (P < .05). Participants appear to have sufficient knowledge and proper attitudes regarding hand hygiene; however, compliance practices were
suboptimal. Level 4
Maheshwari, V. (2014) Cross sectional study The attitude regarding correct hand hygiene practices to be followed at all times was found to be better among nurses (62.5%) as compared to residents
(21.3%) which was found to be highly significant with p-value <0.001. Level 4
Bello, S., Effa, E. E., Okokon, E. E., & Oduwole, O. A. (2013). Cross sectional study Nurses had significantly higher hand wash frequency per patient contact than other healthcare providers.
Majority (78.5%) of participants knew that hands should be washed for at least 15 seconds, for effective prevention of nosocomial infection. Level 4
Mu’taz, M. D., Alrimawi, I., Saifan, A. R., & Batiha, A. M. (2016) Cross sectional study The participants had a moderate knowledge regarding the hand hygiene (m = 6, SD = 1.7). They had a better
attitude score than practice with a mean of 82.5 ± 8.8. Level 4
AlSaleh, M., AlHazzaa, A., AlOmran, A., AlJamaan, F., AlSalman, M., & AlSaleh, E. (2016) A cross sectional study A small proportion of males (23.5%) and females (27.6%) had positive attitudes
towards feeling frustrated when others pass over hand hygiene (?2 = 9.56, P = 0.023). And 36.3% of males compared to 30.6% of females reported that they always adhere to correct hand hygiene
practices at all times (?2 = 6.42, P = 0.093) Level 4
Mahmood, S. E., Verma, R., & Khan, M. B. (2015). Cross sectional study A higher proportion of them routinely used alcohol based hand rub (52.0%). Nearly 28% had poor knowledge and 72% had moderate
knowledge regarding hand hygiene. Level 4

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