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P: People with depression

I: Use of antidepressants

C: Combination and antidepressants and psychotherapy

O: Depression decreased greatly.

T: Six weeks

With depressed patients, how does the use of a combination of antidepressants and psychotherapy treatments compared to the use of antidepressants successfully improve patient symptoms within six weeks’ time period?

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Monitoring for Hand Hygiene Compliance and its Effectiveness at Preventing Healthcare-Associated Infections

Your Name

July 15, 2019



Monitoring for Hand Hygiene Compliance and its Effectiveness at Preventing Healthcare-Associated Infections

Despite the vast body of evidence that correlates proper hand hygiene practices amongst healthcare providers with a decrease in the incidence of healthcare-acquired infections (HAIs), or infections contracted during admission to a healthcare facility, recommended hand hygiene compliance (HHC) continues to be a challenge (Gupta, Gupta, & Bhaskar, 2018).  This paper will explore the issue by providing a brief background, discussing the importance to this author, nurses, and the nursing profession, outlining a related clinical question, highlighting current research on the topic, and talking about how this topic can be implemented in nursing practice, both on an individual level, and on a systems level.  This author will then present information on how to translate the importance of this issue to the client population through education.

Introduction, Significance, and Importance of Hand Hygiene

When discussing hand hygiene in healthcare, this author is referring to the rudimentary practice of healthcare providers, including nurses, either washing their hands with soap and water or using an antiseptic hand wash or rub, like an alcohol-based hand sanitizer.  Centers for Disease Control and Prevention (CDC) (2018) recommends to clean hands before and after contact with clients, after touching items that are close to the client, before and after wearing gloves, after using the restroom, and before eating. Additionally, antiseptic rubs may not be used if the client has Clostridium difficile (CDC, 2018).

The importance of hand hygiene practices can be traced back to the days of Florence Nightingale, who championed the cause by promoting hand hygiene when nursing soldiers during the Crimean War.  Despite this longstanding knowledge, HHC continues to be problematic, and potentially preventable HAIs are still occurring in healthcare today.  It is estimated that healthcare providers are only washing their hands 50% of the times they should, which very well could be contributing to the one in 25 patients who acquire a HAI (CDC, 2018).  In the United States, about 80,000 people die annually as a result of HAIs (McCalla, Reily, Thomas, & McSpedon-Rai, 2017).  This author has cared for many patients who acquired HAIs.  It is for these reasons that this author has chosen the topic as it impacts both the individual nurse and the nursing profession.

There are many reported reasons why healthcare providers remain out of compliance with recommended hand hygiene.  Some identified by Gupta et al. (2018) include a lack of knowledge by the healthcare provider, hand hygiene products that are difficult to find, or placed in out-of-the-way locations, and emergent situations where healthcare providers have to act fast.  Masroor, Doll, Stevens, & Bearman (2017) also add that frequent hand hygiene products can be extremely irritating to healthcare providers’ skin which can be as often as 100 times during a 12-hour shift (CDC, 2018).

To ensure proper HHC, as well as lower HAIs and healthcare costs, many healthcare facilities follow the practice of monitoring healthcare workers.  The gold standard is direct observation, having someone who is trained watch to see that healthcare workers are washing their hands when they are supposed to (Masroor et al., 2017).  As Masroor et al. (2017) note, drawbacks to direct observation are that it is not possible to watch everyone all the time, and when people know they are being watched, they often do what they are supposed to.  This is referred to as “The Hawthorne Effect” (Masroor et al., 2017).

Another method for monitoring HHC is to track how much product (hand sanitizer, soap, paper towels, etc.) is used (Masroor et al., 2017).  This is relatively easy and provides objective data.  One drawback to this method is that only monitoring supplies does not convey who is using the products, or if they are being used as recommended for HAI prevention (Masroor et al., 2017).

A third method to tracking HHC is automated hand hygiene monitoring systems which typically involve a healthcare employee wearing a tracking device that registers and tracks when hand hygiene is performed (Masoor et al., 2017).  The benefits are that more hand hygiene events can be tracked, and feedback can be given to specific employees.  Drawbacks are that these systems are expensive and that employees might not want to wear them for fear of what could happen or how the data will be used.  For some, monitoring is an ethical issue. Lastly, the devices may not be 100% accurate, especially in busy workflow areas (Masoor et al., 2017)

PICOT Question

In nursing science, questions are often formulated utilizing the PICOT format (Population or Problem, Intervention, Comparison, Outcome, Time) to provide a structure for research and the dissemination of best nursing practice (Elias, Polancich, Jones, & Colvin, 2015).  This author developed the following clinical question in response to the ongoing morbidity and mortality related to HAIs; in the inpatient population, does the use of electronic monitoring of healthcare provider hand hygiene compared to not using electronic monitoring, decrease the incidence of healthcare-acquired infections?

Current Evidence

Research Study #1

Researchers Kelly, Blackhurst, McAtee and Steed (2016) looked at 33 months of data from hospital units who had electronic systems for monitoring HHC and compared the use to the number of incidents of healthcare-associated methicillin-resistant Staphylococcus aureus (MRSA).  The results were an overall increase in HHC, 25.5% from baseline, and a 42% reduction in instances of MRSA (Kelly et al., 2016).  Kelly et al. (2016) also found that with this monitoring in place, the healthcare facility saved around $434,000.  The researchers discussed that one aspect of this study that appeared to improve HHC was the involvement of nursing leaderships’ ongoing feedback and support to the nursing staff providing client care.

Research Study #2

Sickbert-Bennet et al. (2016) conducted a study over 17 months, where they observed hand hygiene practices both with direct observation and with video surveillance in clients’ rooms.  They encouraged healthcare providers across all disciplines (nursing, medicine, therapists, food service, etc.) to give immediate feedback when observing a person not in compliance (Sickbert-Bennet et al., 2016).  What Sickbert-Bennet et al. (2016) found was a 10% increase in HHC, 197 fewer HAIs (14%), 22 fewer deaths, and more than five million dollars in savings.  This study shows that there is always room for improvement in HHC and that speaking up when someone is not compliant is essential to protecting clients.

(Optional) Research Study #3

McCalla et al. (2017) compared HHC using trained humans directly observing the practice and compared it to HHC using an automated device, Biovigil, which requires caregivers to wear a device that flashed yellow and red until hand hygiene was performed when the light would turn green.  The badge also makes a sound to trigger HHC (McCalla et al., 2017).  Incidence of multidrug-resistant organisms (MDROs) and other HAIs were also recorded during this study.  What McCalla et al. (2017) found is that the human observations yielded higher levels of HHC (100% quarters 1-3 and 96% quarter 4) compared to 95% compliance with automated HHC monitor.  Researchers also noted a slight reduction in HAIs, but note more research is needed (McCalla et al., 2017).

Implementation in Nursing Practice

Based on the research, this author was able to find very few studies conducted specifically on the use of electronic monitoring for hand hygiene and infection control.  Numerous studies show that compliance with hand hygiene decreases HAIs, and other studies show that electronic surveillance can increase HHC, though not always as much as with human observation (McCalla et al., 2017).  McCalla et al. (2017) do note that automated surveillance increases the number of observations recorded.  It is logical then to hypothesize that increased use of electronic monitoring can lead to a reduction in HAIs, but certainly, there is a need for more nursing research on the topic.

Individual Level

There are many implications for individual nursing practice.  One is for every nurse to intentionally follow recommended hand hygiene practices and make a concerted effort to prevent the spread of HAIs.  Nurses must pledge and commit to hand hygiene and complete it correctly every time.  Nurses should educate themselves on proper technique and where hand hygiene resources are located in their facility.  Finally, nurses need to speak up if they see other employees, including healthcare providers, who are out of compliance with hand hygiene practices.


There are many recommendations and implications for healthcare systems, facilities, and specific units to enhance HHC.  It is essential that systems not only have standard operating procedures and policies in place for hand hygiene, but that they provide proper training to staff upon hire, and on an ongoing basis (Gupta et al., 2018).  Supervisors or trained personnel should be designated to monitor employee compliance and facilities need to ensure supplies are readily available, as training is limited in its effectiveness if the necessary tools are not available and placed in locations conducive to use.  This includes providing sinks with soap as well as antiseptic hand cleansers.  Facilities should have ways to monitor healthcare providers to ensure HHC.  As research as shown, electronic surveillance can reduce the number of HAIs; thus, facilities should consider incorporating them into existing monitoring practices.  The use of an interdisciplinary HAI Committee could be put in to place to collaborate across professions to ensure employee education is provided, and compliance is met.

Client Education

            The health of clients is central to the practice of hand hygiene, and client education is an essential component of ensuring HHC.  Many clients view healthcare facilities as places to improve their health, and many are unaware of the risks of contracting an illness while receiving care. Clients should know the chances of developing an HAI and their role in prevention. It is equally important that they know it is ok to ask healthcare providers to wash hands.  The CDC has excellent resources for clients related to the topic of hand hygiene (See Appendix).


Hand hygiene is a skill that in itself is so basic, yet so fundamental in the prevention of HAIs.  The barriers, both perceived and real, to proper hand hygiene practices must be addressed and overcome across all levels of care.  Nurses and healthcare organizations need to commit to the strict adherence of recommended hand hygiene and invest resources for monitoring HHC to protect the clients and communities they serve.




Centers for Disease Control and Prevention (2018, May 3). Hand hygiene in healthcare settings. Retrieved from https://www.cdc.gov/handhygiene/index.html

Elias, B. L., Polancich, S., Jones, C., & Colvin, S. (2015). Evolving the PICOT method for the digital age: The PICOT-D. Journal of Nursing Education, 54(10), 594-599. doi:10.3928/10484834-20150916-09

Gupta, R. R., Gupta, R. K., & Bhaskar, S. V. (2018). What hampers infection control practices in the Intensive Care Unit (ICU) of a general hospital? Indian Journal of Public Health Research and Development, 9(3), 119-124. doi: 10.5958/0976-5506.2018.00194.8

Kelly, J. W., Blackhurst, D., McAtee, W., & Steed, C. (2016).  Electronic hand hygiene monitoring as a tool for reducing healthcare-associated methicillin-resistant Staphylococcus aureus infection. American Journal of Infection Control, 44(2016), 956-957.  http://dx.doi.org/10.1016/j.ajic.2016.04.215

Masroor, N., Doll, M., Stevens, M., & Bearman, G. (2017). Approaches to hand hygiene monitoring: From low to high technology approaches. International Journal of Infections Diseases, 65, 101-104. https://doi.org/10.1016/j.ijid.2017.09.031

McCalla, S., Reilly, M., Thomas, R., & McSpedon-Rai, D. (2017). An automated hand hygiene compliance system is associated with improved monitoring of hand hygiene. American Journal of Infection Control, 45(2017), 492-497. https://doi.org/10.1016/j.ajic.2016.12.015

Sickert-Bennett, E. E., DiBiase, L. M., Schade-Willis, T. M., Wolak, E. S., Weber, D. J., & Rutala, W. A. (2016). Reduction of healthcare-associated infections by exceeding high compliance with hand hygiene practices. Emerging Infectious Diseases, 22(9), 1628-1631. http://dx.doi.org/10.3201/eid2209.1514400




Client Education: Hand Hygiene

For every 25 people who are in the hospital, one develops an infection, and every year 80,000 people die from diseases that they get in the hospital (CDC, 2016).  Hospital workers may carry germs from one patient to another.

Clean hands prevent the spread of infections.  Here is what you can do to protect yourself or your loved one during your hospital stay:

  • Clean your own hands
  • Ask your visitors to clean their hands. For example: “I am focused on getting better, can you please rewash your hands?”
  • If you don’t see your healthcare provider clean their hands, it is OK to ask them to For example: “I didn’t see you wash your hands, can you please do it again so I can see?”

When to wash your hands:

  • After you use the restroom
  • Before you eat
  • After you touch things in the hospital (railings, doorknobs, light switches, elevator buttons)
  • Before you touch your face
  • After you blow your nose
  • Before you touch a sore or wound or dressing

How to Wash Your Hands with Soap and Water

  • Under warm water rub a dime-sized amount of soap between your hands for 15 seconds. Make sure to rub all over your hands, fingers, and between your fingers
  • Rinse your hands with warm water
  • Dry your hands with a paper towel. Use the towel to turn the water faucet off and open the bathroom door.

How to Wash Your Hands with Hand Sanitizer

  • Squeeze a nickel-size amount of hand sanitizer into your hand and rub hands together for at least 15 seconds until your hands are dry.

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