Abstract
Hand washing is the foremost practice fundamental to hospital safety precautions. Hospital-associated infections account for a significant disease burden and mortality and increase medical spending (Magill et al., 2014). The objectives of the proposed quantitative study are to compare the pre- and post-intervention hand washing (HW) skills of nurses and assess the impact of HW training on surgical-site infection rates. It will use a quasi-experimental design to compare pre-test and post-test data. A random sample of 25 registered nurses working at surgical wards of a selected hospital in the US will receive a 4-week online educational intervention.
Their HW knowledge scores before and after the program, as measured using a designed questionnaire, will indicate the efficacy of training. Also, a comparison of pre- and post-intervention surgical-site infection rates will show that hand washing is an effective infection control measure. The proposed study has significant implications for practice. First, a decrease in surgical-site infections after the training will affirm that HW educational programs designed for healthcare workers could reduce hospital-associated pathological states. Thus, hospitals and nursing schools will emphasize handwashing as an important safety practice. Second, higher HW knowledge scores after the intervention will indicate that skills deficit is the leading cause of low compliance with HW guidelines. It will show if refresher courses are needed to improve awareness and adherence to patient safety practices, including hand hygiene.
Introduction
Hospital-associated infections (HAIs) account for substantial morbidity and mortality rates, particularly among post-surgical patients. Magill et al. (2014) estimate that about 722,000 hospital-acquired infections (HAIs) were reported in U.S. healthcare facilities in 2011 alone, causing 75,000 deaths annually. Thus, the high prevalence of HAIs has significant implications for patient safety, care quality, and health care costs. Inpatients may contract procedure- or device-related HAIs, such as ventilator-associated pneumonia complications, gastrointestinal diseases, or surgical-wound infections, among others, during admission. Post-surgical patients are prone to central-line bacteremia and catheter-related urinary tract infections (UTIs) (Magill et al., 2014). The leading cause of HAIs is pathogen transmission from the hands of nurses and doctors involved in direct inpatient care (Magill et al., 2014).
Most HAIs can be prevented through transmission-based precautions. Hand washing (HW) is an effective measure for preventing HAIs in hospital settings (Ellingson et al., 2014). Following recommended hand hygiene practices are, therefore, critical in combating nosocomial infections. Healthcare workers (HCWs) can utilize a detergent and water or alcohol-based formulations to sanitize their hands before and after surgery (Ellingson et al., 2014). However, poor compliance with these procedures is a growing issue of concern in hospitals. Surgical staff nurses have a role to play in preventing HAIs given their direct involvement in surgical-wound care and recovery. Therefore, compliance with hand hygiene practices by this population would help reduce HAI prevalence in hospitals and improve post-surgical outcomes. Educational programs, reminders, and surveillance systems can bolster the capacity of the nurses to adhere to hand hygiene practices.
The Problem and Its Significance
HAIs present a significant problem in hospital performance improvement. In the US, about 722,000 cases are reported annually with 75,000 of them resulting in deaths (Magill et al., 2014). The prevalence of HAIs in the US is 3.5-9.9% based on the World Health Organization (WHO) estimates, and it is associated with a significant economic burden on the healthcare system through an extended length of stay (LOS) and increased readmission episodes (Park et al., 2014). Further, HAIs account for higher morbidity and mortality rates among inpatients. HAIs are often UTIs, surgical wounds, and respiratory infections, such as pneumonia, and the most frequently result from contaminated hands of caregivers (Magill et al., 2014).
Hand washing is fronted as an effective measure for curbing pathogen transmissions in hospital settings (Ellingson et al., 2014). By simply washing one’s hands with soapy water or alcohol-based detergents, the risk of transmitting infections to patients decreases significantly. However, low compliance rates of less than 50% reported in some hospitals present a challenge to nosocomial infection prevention (Ellingson et al., 2014). HAIs, however minor they may be, often increase LOS and patient readmissions. In surgical wards, the most reported HAIs include wound infections, which result in a prolonged stay in the facility and discomfort and cause a significant economic burden to patients (Magill et al., 2014).
The scope of HAIs extends to post-surgical units, where life-threatening surgical-wound infections constitute about one-quarter of all HAIs (Magill et al., 2014). The risk factors include poor post-operative care quality, patient’s inability to follow instructions, and resident microbes in a hospital environment. Hand washing is perhaps the most important surgical-wound infection control measure. It is associated with lower HAI cases in hospital settings. The proposed research will evaluate surgical-site infection rates when nurses receive training on handwashing to give empirical evidence for antisepsis preparation as an effective postoperative-wound infection control strategy. The findings will help hospitals to improve their hand hygiene practices and staff compliance with institutional guidelines for better performance.
Definitions
The key concepts investigated by this study and their definitions are as follows:
- Hand washing – refers to routine disinfection practices or antisepsis actions meant to reduce the risk of hospital-acquired infections
- Hospital-associated or nosocomial infections – are pathological states occurring in inpatients that were lacking during hospitalization
- Inpatient – an individual receiving institutional care at a hospital or any healthcare center
Theoretical Rationale
The planned behavior theory (PBT) is utilized in this research to give a theoretical background to the study. PBT is a decision-making framework, which holds that social behavior is predicated on individual perceptions that are modulated by two factors: “attitudes and beliefs about behavioral control” over the situation (Javadi, Kadkhodaee, Yaghoubi, Maroufi, & Shams, 2013). Subjective norms determine one’s drive to pursue a specific outcome. The normative beliefs comprise the expected goals of a group or individual. On the other hand, perceived behavioral control describes a person’s capacity to display a particular behavior, and it is influenced by individual subjective norms (Javadi et al., 2013). Therefore, nurses’ control and normative beliefs shape the intent to use hand-washing practices to improve post-surgical outcomes.
Need for the Study
Inappropriate hand-hygiene practices are associated with an increased risk of nosocomial infections (Park et al., 2014). For this reason, multimodal hygiene programs are recommended for facilities intending to improve HAI indicators. They include hospital staff training, compliance monitoring and reporting, and patient education (Ellingson et al., 2014). Previously, investigators measured hand-washing adherence through the observation method, which is prone to researcher bias. Further, the approach is time-consuming, as one has to observe hygiene events over a long period.
The quantitative design used in the proposed study will enhance the generalizability of its findings. It will involve an evaluation of nursing knowledge and surgical-site infections before and after nurse preparation on handwashing at a surgical unit. The quantitative measurement of the effectiveness of the educational program designed to promote skills and awareness of hand disinfection will provide findings with greater external validity. It will also demonstrate that surgical nurses’ hands become tainted with pathogenic microorganisms after each episode of bedside care. Healthcare facilities could use the study’s findings to promote the hand-decontamination skills of the nursing staff as a strategy for reducing HAI rates and improving hospital quality performance and rating. The findings also have a potential application in academic settings. The nursing schools could use the results to design curricula that emphasize on handwashing as an evidence-based practice.
The study will contribute to theory development by establishing the connection between hand-washing education and HAI rates in a surgical ward. The PBT framework attributes behavior to normative and control beliefs of a person or group. The study will establish if these attitudes predict hand-washing behavior in surgical units. It will demonstrate if education influences the nurses’ safety intentions, which will be indicated by post-intervention HAI rates.
The study’s results have the potential to improve nursing practice through enhanced awareness of the significance of handwashing in decreasing HAIs. Staff nurses, as the professionals involved in direct patient care, must be at the forefront of efforts to promote patient safety. Routine hand hygiene practices can lower morbidity and mortality and reduce hospital spending – a key quality indicator. Therefore, the knowledge gained from this study will have potential applications in hospitals and academic settings.
Research Objective
- To compare pre-intervention and post-intervention handwashing skills of surgical staff nurses.
- To assess the impact of handwashing training of nurses on surgical-site infection rates.
Review of Literature
Hospital-acquired infections are an issue of major public health concern in the US, where the prevalence stands at 3.5-9.9% (Park et al., 2014). They cause significant morbidity and mortality and strain the health care system through extended LOS and readmissions. In hospitals, about one-quarter of HAIs are surgical-site infections and are attributed to inadequate postoperative care and pathogens harbored on the hands of healthcare professionals and patients (Magill et al., 2014). Therefore, prevention of HAIs in the surgical wards is critical.
Pathogens may find their way into the surgical site through contact with staff nurses and potentially elevate a patient’s risk of contracting an infection. Further, the invasive procedures, including operative interventions, increase this population’s vulnerability to HAIs (Part et al., 2014). Other procedures such as central-line catheters and intravenous (IV) administration or feeding also increase the HAI risk. Device-associated infections increase LOS and readmission rates, cause pain, and involve substantial health care costs (Magill et al., 2014). A significant proportion of these HAIs develops from catheter-related bacteremia, UTIs, and ventilator-related pneumonia. Therefore, interventions for preventing HAIs focus on these three areas. Procedure-related infections arise from transmissions occurring during operative procedures, including colon surgeries (Magill et al., 2014). The period before HAI symptom onset ranges 48 hours and six days after admission into a surgical ward (Magill et al., 2014).
HCWs attend to many patients with diverse illnesses and touch body fluids, gowns, and instruments that may harbor pathogenic microbial communities (Ellingson et al., 2014). Therefore, due to these interactions, their hands are prone to contamination by pathogens resident on the skin, blood, surfaces, etc. Routine hand hygiene is necessary to reduce transmission risk. From the WHO recommendations, hand washing with soapy water or antiseptic agents is an effective strategy for preventing contagious diseases (Park et al., 2014). The transmission of pathogens that cause HAIs often occurs during patient contact. It may involve a physical touch of a patient by a doctor or nurse during procedures, catheter insertion or removal, wound dressing, etc. (Al-Tawfiq, Abed, Al-Yami, & Birrer, 2013). In addition to standard safety measures, washing hands with an antiseptic soap before and after each patient contact or routine operation is fronted as an evidence-based intervention for curbing HAIs (Al-Tawfiq et al., 2013). HWCs can also use alcohol-based preparations to disinfect their hands. These disinfectants wipe out transient microbes, and thus, reduce the risk of HAIs.
Although guidelines and protocols exist for hospitals, compliance is usually a challenge. In most instances, HCWs fail to disinfect their hands as recommended, posing a risk to patients. According to Park et al. (2014), compliance levels sometimes drop to as low as 50% across most units and HCW categories. Further, factors such as patient needs and intensive care requirements in hospital settings reduce adherence to hand hygiene practices. Therefore, increasing compliance with this measure is a critical quality improvement goal of any facility. Educational interventions, awareness campaigns, digital reminders, and regular monitoring and feedback have been adopted by hospitals to enhance adherence (Al-Tawfiq et al., 2013). The goal is to remove barriers to compliance and achieve positive behavior change among HCWs.
Staff nurses, as the professionals with the highest patient contact hours, are implicated in the transmission of HAIs. They care for inpatients admitted to different hospital wards until they are ready for discharge. Given their critical role in bedside care, they constitute an important part of a hospital’s HAI control team (Rock, Harris, Reich, Johnson, & Thom, 2013). As such, they should possess adequate knowledge in infection management to play a leading role in quality improvement initiatives. Studies suggest that there is a skills gap in nurses’ understanding of safety measures with most of them indicating that gloves are an effective substitute for handwashing (Rock et al., 2013). Further, some of them sanitize their hands after patient contact. Thus, a good knowledge of HAI management is lacking among HCWs, which could account for the high prevalence of nosocomial infections in hospitals.
In conclusion, from the studies reviewed, interventions for reducing HAI rates are required in hospitals. The primary target areas of such measures should be skill development of HCWs, compliance improvement, and provision of hand sanitizing implements. Since compliance with handwashing guidelines is low in healthcare settings, the risk of HAIs is high, especially in critical environments such as surgical wards. Therefore, measures designed to promote awareness of these practices are required in hospitals. In this view, educational programs intended to improve the knowledge of HCWs on safety precautions should be emphasized to address compliance issues. Therefore, the proposed study’s objective is to evaluate the impact of training on staff nurses’ hand washing skills and compare pre- and post-treatment surgical-infection rates.
Methods
Research Design
Strategies for comparison of groups
The proposed study will use a quasi-experimental approach to compare the pre- and post-intervention skills of staff nurses and surgical-site infection rates. Therefore, it will involve a comparison of two groups: pre-test and post-test arms. The pre-intervention subjects’ knowledge of handwashing (HW) before and after each patient contact will be compared with post-intervention HW skills. The intervention will involve a structured training program on HW designed for surgical staff nurses.
Controlling extraneous variables
Confounding factors that could potentially affect this study include compliance levels, availability of HW equipment, and recall rates. The training will emphasize the significance of adhering to hand-washing guidelines as a quality improvement measure to decrease HAI rates in the ward. The facility will provide soap and water and alcohol-based rubs to the subjects during the study. Digital reminders will ensure that nurses wash their hands before and after each patient contact.
Data collection points
Quantitative data will be collected twice during this study. First, before the educational intervention is provided, the subjects’ HW knowledge and surgical-site infections at the ward will be measured. Second, after the program, the nurses’ HW skills and HAI rate will be assessed. A comparison of the two datasets will show if hand-washing training reduces surgical-site infections at surgical wards.
Experimental Interventions
As mentioned before, the study will use a quasi-experimental approach with a one-group pre- and post-intervention design. It will not include treatment and control arms; instead, a sample of staff nurses from a surgical ward of a hospital will be used to test the efficacy of the intervention. The subjects’ knowledge and the unit’s HAI rate will be assessed at the pre- and post-test data points.
Sampling Plan
Definition of the population
A study population includes all individuals or objects targeted by the investigator. Typically, a census or headcount can give the number of potential subjects from which a researcher can draw a sample using a specified sampling frame. In the proposed study, the target population will comprise all staff nurses working at a surgical ward of a selected hospital in the US. It will be based on the facility’s record of the nursing workforce at this unit at the initiation of data collection.
The specific sampling design
The sample will be selected from surgical staff nurses. The study will use a simple random sampling method to draw subjects who will take part in the study. Based on the target population, representative sample size will be obtained taking into account demographic characteristics, such as age, gender, educational level, and years of experience.
Recruitment of study participants
The study will use a passive approach to recruit subjects. This method varies from active recruitment in the role the investigator plays during sampling. While the passive method does not require the researcher to participate proactively in choosing subjects, the active approach entails contacting potential participants and recruiting them into the study. Therefore, the nurse manager of the surgical unit will be involved in participant recruitment. The approach will help reduce researcher bias, a potential threat to external validity. Using the ward’s staff population as the sampling frame, a representative sample will be recruited to take part in the educational intervention.
Inclusion/exclusion criteria
They include the basis for determining whether a potential subject is eligible to participate in this study or not. The inclusion criteria are:
- Registered nurses (RNs) possessing at least a Bachelor of Science in Nursing or equivalent qualifications
- Staff nurses providing direct care to postsurgical patients for a minimum of one year at a selected US healthcare facility
- RNs that will be accessible to the researcher during the planned data collection period
- RNs who consent to take part in a training program on handwashing
The exclusion criteria define the individuals not eligible to participate in the research as follows:
- RNs who have gone through a training on handwashing practices before
- Nurses who are not involved in caring for postoperative patients
The number of participants expected and its rationale
The sample size anticipated for this research will be about 25 staff nurses based on the assumption that 10% of the target population in the hospital will give adequate statistical power to establish an effect. Therefore, assuming the facility has 250 RNs in its surgical wards, 10% of this number will give 25 subjects. The study will measure the participants’ HW knowledge and hospital HAI rate before and after an educational intervention.
Data Collection Methods
Specific facilities
The study will require web-based informational booklets and laptops for educational intervention. Other requirements include running water, antiseptic soap, and alcohol hand rub supplied at the surgical ward. The aim is to ensure that staff nurses comply with HW practices after the training.
Equipment to be utilized to collect data
The tool developed to obtain quantitative data from the subjects is a closed questionnaire. It will be designed after an in-depth review of relevant literature, pilot reviews, and test-retest studies to ascertain the content validity of the questions. The tool will be used to obtain demographic data and assess the HW skills of the subjects. As such, it will comprise two parts. The first section will collect information on five variables: age, gender, level of education, experience (in years), and workstation. The second part will evaluate the subject’s pre- and post-intervention HW knowledge levels. Another instrument that will be used in data collection is a chart indicating reported HAI episodes in the surgical ward.
Procedures to be adopted to assign participants to groups
The study will assess two dependent variables – HW skills and HAI rate – before and after an intervention. Therefore, it will not involve an assignment of subjects into the treatment and control groups.
Operational Definitions
The key independent variable (IV) and dependent variables (DV) that will be operationalized as follows:
- Handwashing training (IV) – refers to a structured instruction to improve staff nurses’ knowledge of standard hand hygiene practices for better postoperative wound care.
- Hand hygiene knowledge (DV) – refers to the skills gained from a teaching program on HW practices in surgical units.
- Surgical-site infections (DV) – are the HAIs that occur within 30 days after an operation.
- Staff nurses – are the nursing professionals (RNs) providing care in surgical wards of a hospital.
Measurement Instruments for Data Collection
Name of the instruments
The study will use two tools to collect data: an HW questionnaire and an HAI episode chart. The two will measure the dependent variables investigated in this research. A comparison between pre- and post-test measures will indicate the efficacy of the educational intervention.
Description
As stated above, the HW questionnaire will comprise two sections: demographic details and HW knowledge assessment. The researcher will ascertain the content and face validity of the instrument before data collection. Experts will be engaged in reviewing the knowledge measurement items and rating them as either having appropriate or inappropriate content. Those with low scores will be revised to reflect the reviewer’s comments. Face validity, i.e., grammar, clarity, and relevance of the items, will be ascertained through pilot reviews involving staff nurses. The test-retest procedure conducted 14 days apart with a sample of five staff nurses will be used to evaluate instrument reliability. If the retest scores are similar to test results, then the items will be deemed reliable. The HAI episode chart will collect data on the surgical-site infections occurring at the facility.
Actual instruments
A copy of the HW questionnaire and HAI chart are attached in Appendix A and B, respectively.
Data Analysis
This quantitative study will not use coding – a strategy applied to qualitative data. The analysis plan will involve sorting and entering the data from the HW questionnaire and HAI chart into the Statistical Package for Social Scientists (SPSS) software for descriptive and inferential analysis. Thus, the procedure will proceed in two steps. In descriptive statistics, the frequency and dispersion of the demographic characteristics of the subjects will be determined. This method will also give the mean and variance of HW knowledge among staff nurses in the surgical ward. In inferential statistics, a t-test will be employed to compare the pre- and post-intervention data on HW knowledge of the subjects. Additionally, chi-square tests will be utilized to establish a correlation between post-intervention HW knowledge values and age, educational level, or years of experience.
Methods of Safeguarding Human Subjects
Maintaining confidentiality
Since the study will involve human participants, efforts will be taken to protect their rights. Respondent confidentiality will be maintained through unique identifiers. The nurse manager will recruit the sample and assign subjects codes that they will use throughout the 4-week HW educational program. Moreover, the training will be entirely web-based to maintain the participants’ anonymity. Data collection will also involve a questionnaire sent to the subjects via email to ensure confidentiality and privacy throughout the research process. Further, the demographic data collected using this instrument will not include the participant’s name or address.
Securing informed consent
The subjects will receive a participant information sheet informing them of the study’s purpose, design, and potential benefits to the facility and nursing profession. Subsequently, a consent form will be sent to the subjects (Appendix C). It will indicate the title of the investigation and the obligations of the participants, including the right to withdraw from the research. Those who will sign and send the forms will be deemed to have consented to participate in the study.
Minimizing risks
Possible harm to participants may come from the time spent online during the training. However, the educational intervention will be designed in such a way that it allows each participant to log-in and retrieve the materials at his/her convenience. Subjects will not be subjected to more harm than they would experience in their routine tasks. The sample will not include participants from vulnerable groups. Also, the subjects’ identities or addresses will not be revealed during and after the study. No monetary incentive will be awarded for participating in this study but the researcher will emphasize the significance of the research to nursing practice when seeking consent.
References
Al-Tawfiq, J. A., Abed, M. S., Al-Yami, N., & Birrer, R. B. (2013). Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections. American Journal of Infection Control, 41(6), 482-486. Web.
Ellingson, K., Haas, J. P., Aiello, A. E., Kusek, L., Maragakis, L. L., Olmsted, R. N., Yokoe, D. S. (2014). Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control and Hospital Epidemiology, 35(8), 937-960. Web.
Javadi, M., Kadkhodaee, M., Yaghoubi, M., Maroufi, M., & Shams, A. (2013). Applying theory of planned behavior in predicting of patient safety behaviors of nurses. Materia Socio Medica, 25(1), 52-55. Web.
Magill, S. S., Edwards, J. R., Bamberg, W., Beldavs, Z. G., Dumyati, G., Kainer, M. A. Fridkin, S. K. (2014). Multistate point-prevalence survey of health care-associated infections. The New England Journal of Medicine, 370, 1198-1208. Web.
Park, H. Y., Kim, S. K., Lim, Y. J., Kwak, S. H., Hong, M. J., Mun, H. M., … Choi, S. H. (2014). Assessment of the appropriateness of hand surface coverage for health care workers according to World Health Organization hand hygiene guidelines. American Journal of Infection Control, 42(5), 559–561. Web.
Rock, C., Harris, A. D., Reich, N. G., Johnson, J. K., & Thom, K. A. (2013). Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time? A randomized controlled trial. American Journal of Infection Control, 41(11), 994–996. Web.
Appendices
Appendix A: HW Questionnaire
Section A: Demographic Information
Age (yrs) ——————-
Gender: Male —- Female —-
Educational level
College diploma —— BSN ——– Post graduate ——— Others ————
Experience (in years) —————–
Work position at the facility —————–
Part B: Hand Washing Practices
Select the appropriate answer for each question.
- When are alcohol-based hand-rubs not recommended?
- When hands are dirty
- During pre-operative hand washing
- Before the insertion of catheters
- Indicate a statement that is correct out of the following.
- Low compliance with handwashing contributes to hospital-associated infections
- Hand washing is not a must provided gloves are worn
- Hand hygiene is only necessary after a procedure
- How should hands be dried after washing them with soap and water?
- Using single-use cloth towels
- Disposable paper towels
- Hanged multiple-use cloth towels
- All of the above
- Hand washing is recommended:
- Before any patient contact
- After draining a urinary catheter bag
- Before checking a pulse
- All of the above
- Hand washing is not necessary:
- Before administering an injection
- After touching a patient’s skin
- After handling paper
Thank you for your responses.
Appendix B: HAI Incidents Chart
Date ________________
Nature of hospital-acquired infection
- Device-associated __________________
- Procedure-associated ________________
Probable cause ________________
Responses ________________
Appendix C: Consent Form
Title of the study
Infection Prevention in Hospitals: The Importance of Hand Washing among Surgical Staff Nurses
Please check in each box
- I confirm that I have read and understood the information sheet for the above study and have had the opportunity to ask questions.
- I understand that my participation is voluntary and that I am free to withdraw at any time without giving a reason.
- I recognize that I can refuse to answer a question or set of questions
- I agree to take part in the study.
Please tick box yes no
5. I agree with the use of anonymized quotes in publications
- Signature:________________
- Date:________________
- Name of researcher:________________
- Signature:________________
- Date:________________