Problem description

Numerous measures have been implemented to facilitate the processes of care delivery and minimize the risk of complications during care delivery. Nurses are tasked with the primary responsibility of providing patients with high-quality care to improve the chances of better health outcome as well as the quality of life (Heister, Kaier & Wolkewitz, 2017). However, the dynamic nature of the modern health care system and the increased population of patient increase the risk of cross-infection in healthcare settings. Studies have revealed that failure to follow the established standards of care together with a disregard of patient-centered care predisposes patients to the risk of complications and poor health outcome. For instance, non-compliance with hand hygiene protocol aggravates the risk of health acquired infections in healthcare settings (Puchter et al. 2018). Nosocomial infections have been categorized amongst the major health challenges that currently face the health care system. Nonadherence to hand hygiene has been identified as a major risk factor for nosocomial infections. Studies have revealed the hands of nurses and other care providers involved in the direct care of patients harbor a wide range of pathogenic microorganisms that can be transferred to the patients during care (Khan, Baig & Mehboob, 2017). Despite the measures implemented top address the nosocomial infections menace, these infections are still being recorded in various healthcare facilities. Numerous factors, ranging from personal to organizational are believed to contribute to the non-adherence. These factors include a lack of clear understanding of how nosocomial infections occur and how they can be prevented, a lack of resources and resistance among nurses to embrace preventive measures.

 

 

The significance of the problem

It has been revealed that incidences of nosocomial infections have been on the rise. Noncompliance has been identified as the key contributing factor to the rising rates of these infections (Khan, Baig & Mehboob, 2017). In the United States, for instance, 1 in 25 patients end up contracting nosocomial infections. The complications associated with these infections culminate in the death of over 75,000 annually. It is unfortunate that prevalence of nosocomial infections is highest among patients in the ICU who require specialized care (Tenna, et al. 2013). These infections not only increase the cost of care but predispose patients to poor health outcome and prolonged hospital stay. All health care practitioners are aware that the presence of transient flora in their hands leads to nosocomial infections (Babeluk et al. 2014). Unfortunately, most of them are not sure of the most effective way of preventing the spread of microorganisms.

Current practice related to the problem.

The lack of clear understanding regarding the most effective intervention for nosocomial infections has generated confusion whereby many nurses opt for the conventional soap and water hand washing strategy as compared to the use of disinfectants. Other nurses, however, prefer to use alcohol-based hand rubs despite the doubts of the effectiveness of this strategy. Moreover, nurses do not utilize all hand washing opportunities during care. Hand hygiene guidelines have identified the relevance of nurses observing hand hygiene prior to their contact with patients as well as when their hands are dirtied during care delivery (Youssreya, Hanan & Esraa, 2013).

Impact on background

Nosocomial infections have a negative impact on projected health outcomes. The presence of these infections may thus have a negative implication on the reputation of the care providers and the organization.  In most cases new and junior nurses observe the actions of their seniors. If the seniors demonstrate a culture of confusion in regards to the use of various hand hygiene products that confusion is passed down to the new nurses.

PICO

The project will use the PICO format to help determine the most effective hand hygiene intervention between conventional soap and water and alcohol-based disinfectants. The population targeted in this project is the intensive care unit, nurses. These professionals were selected based on their nature of work. They deal with critically ill patients with limited capacity to participate in personal care. The risk of infections is highest in the ICU due to the critical condition of patients.

Pico table

P

Population
ICU Nurses

I

Intervention
Alcohol based disinfectants

C

Comparison
Soap and water

O

Outcome
Reduced nosocomial incidences

PICO question

The Pico question used in this project is does the use of alcohol-based disinfectants among nurses in the intensive care unit, as compared with conventional soap and water, decrease the incidences of nosocomial infections?

Search Strategy
Keywords

Information to aid in the determination of the most effective hand hygiene intervention was obtained from various peer-reviewed journal articles. The articles were generated from electronic databases using specific search terms. The electronic databases utilized for this task were the PubMed, Medline, EBSCOhost and Cochrane. Some of the search terms used in the paper are nosocomial infections, alcohol-based disinfectants, soap and water, hand hygiene and intensive care unit. The search was expanded and refined through the use of Boolean terms AND, OR and NOT.

Types of Articles generated

The search generated over 700 articles addressing various issues related to nosocomial infections and hand hygiene. The search generated research and non-research articles.  However, all the generated articles could not be used in the paper because they did not satisfy the inclusion criteria. Most of the articles were published over ten years ago and thus were beyond the inclusion range. All articles that had another language of publishing than English were excluded.

Research-based evidence articles

The articles by Babeluk et al. (2014) and Kampiatu and Cozean (2015) are the research-based evidence-based articles used in the project.  Babeluk describes an experimental study aimed at determining the effectiveness of three disinfectant hand sanitizers (Desderman pure gel, Sterillium, and Lavit). The study was conducted in a community setting using medical students as the participants. The researchers found out that the bacterial load in the hands of the participants who used the hand sanitizers was significantly low compared to those that did not use the sanitizers.

Kampiatu and Cozean (2015) describe a controlled, crossover study carried out in three hospital wards to determine whether persistent used of antiseptics reduce the risk of nosocomial infections. Kampiatu argued that inappropriate and irregular use of sanitizers may fail to achieve the anticipated nosocomial reduction initiatives. In this study, over 6000 patient days were evaluated. The overall satisfaction of the hospital staff was evaluated by assessing their response to the questionnaires.

Non-research based evidence articles

The article by Cahtfield et al. (2016) is non-research based evidence aimed at evaluating the experiences of hand hygiene among acute care nurses. The researchers performed qualitative interviews with eight nurses employed in different patient roles. An interpretative phenomenological analysis was used to analyze the data collected in the interviews. The study found out that policy mandated use of disinfectants and personal sense of cleanliness are key factors that influence participation in hand hygiene activities among nurses. The article by Youssreya, Hanan, and Esraa (2013) is non-research based evidence article aimed at determining the perception of knowledge and behavior as well as the attitude of hand hygiene among nurses in the emergency department in a tertiary care facility. The researchers noted that training significantly influences the nurses’ knowledge of hand hygiene practices.

The Evidence Matrix

Authors
Journal Name/ WGU Library
Year of Publication
Research Design
Sample Size
Outcome Variables Measured
Level (I–III)
Quality (A, B, C)
Results/Author’s Suggested Conclusions

Derhun, F. M., et al. (2018).

Use of Alcohol-Based Hand Sanitizer for Hand Hygiene.

 

Journal of Nursing, 12(2):320-8
2018

descriptive, exploratory and quantitative study

27 nursing professionals
Level of Knowledge on hand hygiene
II
High quality (A)
The nursing professionals’ level of knowledge on hand hygiene is insufficient. These professionals need more training on alcohol based preparations to enhance patient safety.

Kampiatu, P., & Cozean J., (2015).

A Controlled, Crossover Study of a Persistent Antiseptic to Reduce Hospital-Acquired Infection.

 

African Journal of Infectious Diseases, 9(1): 6–9.
2015
controlled, crossover study
Six thousand patient-days were evaluated
Satisfaction with alcohol based sanitizer
I
Good quality (B)
The use of alcohol sanitizer minimized incidences of infections

Alcohol based sanitizer had a higher nosocomial reduction capacity as compared to hand washing alone

Babeluk, R., Jutz, S., Mertlitz, S., Matiasek, J., & Klaus, C. (2014).

Hand Hygiene – Evaluation of Three Disinfectant Hand Sanitizers in a Community Setting.

PLoS ONE, 9(11): e111969. https://doi.org/10.1371/journal.pone.0111969
2014
Experimental
 60 healthy volunteers
Participation in hand washing practices
I
Good quality (B)
Alcohol based sanitizers significantly decrease the bacterial load in the hands of users. Many people however, including care professionals are comfortable with the use of certified hand hygiene products as compared to noncertified products.

Chatfield, S. L., Nolan, R., Crawford, H., & Hallam, J. S. (2016).

Experiences of hand hygiene among acute care nurses: An interpretative phenomenological analysis.

 

 SAGE Open Medicine, 4: 1–9.
2016
qualitative interview research
Eight nurses
Nurses perception of hand hygiene
III
Good quality (B)
Nurses are highly likely to adhere to hand hygiene practice if they view the practice from a sense of personal cleanliness as compared to when they perceive it from the perspective of organizational policy.

Youssreya, I., Hanan, S. A., & Esraa, E. (2013).

Perception of Knowledge, Attitude, and Behavior of Hand Hygiene among Nurses in the Emergency Department at King Abdul-Aziz Hospital in Makkah Al Mukaramah.

 

Journal of American Science. 9(5):476-485.
2013
cross-sectional observational study
Sixty  staff nurses in the ED
Behavior, knowledge and attitude of nurses towards hand hygiene
I
High quality
The main finding was that nurses have satisfactory knowledge on hand hygiene practice. Nurses also have a positive perception of the use of alcohol based sanitizers

Training can however influence perception and knowledge on hand hygiene

proposed practice change

The use of alcohol-based disinfectants for hand hygiene practices is the proposed practice change. The effectiveness of these disinfectants is supported by various experimental and clinical studies. These studies have revealed that the use of alcohol-based disinfectants eradicates a larger proportion of transient flora as compared to soap and water (Derhun, 2018). Nurses should be provided with information on the potential benefits of alcohol-based sanitizers to increase compliance. The study findings by Tenna (2013) concur with Derhun (2018) in support of alcohol sanitizers. Tenna (2013) noted that the perception of nurses largely determines their compliance with hand hygiene. Therefore, if practical measures are implemented in support of alcohol-based sanitizers the perception of nurses can be positively changed. The study by Babeluk et al. (2014) also confirmed that alcohol-based sanitizers are more effective in removing transient flora from the hands of care providers. Therefore nurses not only in the ICU but also in other care settings should be provided with alcohol-based disinfectants and encouraged to take part in hand hygiene opportunities. The proposed practice change is also supported by finding from Kampiatu and Cozean (2015) which pointed out that appropriate use of alcohol sanitizers significantly reduces the risk of nosocomial infections. The researchers made it clear that inappropriate use of hand hygiene products leaves the patients as well as the care providers dangerously exposed to pathogenic microorganisms. In their study, Kampiatu and Cozean (2015) noted that no infections were observed in the wards where alcohol sanitizers were used.

Implementation Process
Program stakeholders

The use of alcohol-based sanitizers requires the support of the healthcare administrators and other stakeholders. Even though this is a cost-effective initiative the stakeholders have a valuable role to play to ensure that project achieves the anticipated objectives. The main stakeholders in this project are the ICU nurses, the facility administrators, and the nurse leaders. To ensure that the program becomes a success at all stages of care, the stakeholders will be identified as the champions of change.

The facility administrators’ main role in the program is to allocate resources. The resources necessary for this program are alcohol based sanitizers and hand hygiene sinks which will be set up in areas where nurses can easily access. The nurse leaders will play a crucial role in establishing a culture of compliance with hand hygiene. The nurse leaders will encourage other team members to utilize all hand hygiene opportunities during care delivery. Moreover, leaders will identify the compliant team members for acknowledgment and reward.

The ICU nurses will form a vital aspect of the proposed practice change. These professional provide direct care to patients and therefore their compliance with hand hygiene will alleviate the risk of nosocomial infections. The nurses will be educated on the essence of using alcohol-based sanitizers over conventional soap and water.

Barriers to proposed practice change

Potential barriers to the proposed practice change include limited resources, resistance by the nurses, a lack of commitment by the facility administrators, and poor organizational culture. A lack of commitment by the administrators hampers the allocation of resources. Resistance by the nurses, on the other hand, affects the projects progress. When the nurses are used to conventional hand hygiene strategies, plans to change their practice may be met by resistance. The presence of a poor organizational culture can impact heavily on the proposed practice change (Youssreya, Hanan & Esraa, 2013). For instance, in settings where nurses view hand hygiene as a tiresome practice and a waste of time, initiatives to improve hand hygiene practices may not achieve the intended outcomes.  Such perceptions may lead to extremely low levels of compliance with hand hygiene.

Strategies for overcoming the barriers

A practical strategy to overcome the perceived barriers is the establishment of a change framework. Strategic plans should be developed to address the barriers at the individual and organizational levels. The barriers of limited resources and a lack of institutional commitment can be addressed through providing the administrators with information on the health and economic benefits of the proposed change. Informing the other stakeholders of the benefits of this proposed change can also reduce resistance. Development of a reward system can also improve compliance with the proposed change. All nurses, who demonstrate compliance shall be identified and rewarded appropriately. The involvement of nurse leaders is a practical way of addressing the poor organizational culture that can hamper hand hygiene initiatives. Nurse leaders can encourage the other team members to abandon their negative perceptions on hand hygiene.

Indicators to evaluate the outcome

Decreased incidences of nosocomial infections is a practical indicator of the proposed practice change success. Findings from different studies have revealed that compliance with hand hygiene not only decreases incidences of nosocomial infections but also helps establish a culture that fosters delivery of quality care to the patients. When the care process is pegged on evidence-based practice, an environment is established in which the risk of complications and infections is minimized. Allocation of resources and development of hand hygiene sites are the other indicators that will be used to measure the anticipated outcome. These aspects will reveal that the hospital administration is ready to support the proposed change.

Conclusion

Nosocomial infections have turned out to be a significant health concern since they prolong hospital stays thereby increasing the cost and burden of care. These infections negatively impact on the outcome of care and hence the reputation of the care providers and the organization at large. Even though care providers are trained on preventive measures of hand hygiene, it is unfortunate that many of them are do not the most effective intervention between soap and water and alcohol-based disinfectants. The use of alcohol-based sanitizers is an effective strategy for addressing the issue of nosocomial infections.

References:

Babeluk, R., Jutz, S., Mertlitz, S., Matiasek, J., & Klaus, C. (2014). Hand Hygiene – Evaluation of Three Disinfectant Hand Sanitizers in a Community Setting. PLoS ONE, 9(11): e111969. https://doi.org/10.1371/journal.pone.0111969

Chatfield, S. L., Nolan, R., Crawford, H., & Hallam, J. S. (2016). Experiences of hand hygiene among acute care nurses: An interpretative phenomenological analysis. SAGE Open Medicine, 4: 1–9.

Derhun, F. M., et al. (2018). Use of Alcohol-Based Hand Sanitizer for Hand Hygiene. Journal of Nursing, 12(2):320-8

Heister, T., Kaier, K., & Wolkewitz, M. (2017). Estimating the burden of nosocomial infections: Time dependency and cost clustering should be taken into account. AJIC, 45(1): 94-95

Kampiatu, P., & Cozean J., (2015). A Controlled, Crossover Study of a Persistent Antiseptic to Reduce Hospital-Acquired Infection. African Journal of Infectious Diseases, 9(1): 6–9.

Khan, H.A., Baig, F. K., & Mehboob, R. (2017). Nosocomial infections: Epidemiology, prevention, control and surveillance. Asian Pacific Journal of Tropical Biomedicine, 7(5): 478-482

Puchter, L., et al. (2018). Economic burden of nosocomial infections caused by vancomycin-resistant enterococci. Antimicrobial Resistant Infection Control, 7: 1.

Tenna, A., et al. (2013). Infection Control Knowledge, Attitudes and Practices among Healthcare Workers in Addis Ababa, Ethiopia. Infection Control and Hospital Epidemiology, 34(12): 1289-96.

Youssreya, I., Hanan, S. A., & Esraa, E. (2013). Perception of Knowledge, Attitude, and Behavior of Hand Hygiene among Nurses in the Emergency Department at King Abdul-Aziz Hospital in Makkah Al Mukaramah. Journal of American Science. 9(5):476-485.

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