All hospitalized patients are at risk for hospital-acquired infections. Critically ill patients’ risk for nosocomial infections such as pneumonia is even greater due to a weaker immune system.

Hand Hygiene
Name of the Author
Institution of Affiliation

Abstract
All hospitalized patients are at risk for hospital-acquired infections. Critically ill patients’ risk for nosocomial infections such as pneumonia is even greater due to a weaker immune system. Nosocomial infections increase these patients’ rate of morbidity and mortality. The most common source of infection transmission within the hospital setting is the hands of healthcare professionals. Hence, hand hygiene is the most basic and essential means to prevent the incidence and spread of hospital-acquired infections. Research and evidence-based practice help improve nursing practice and quality patient care. Policies and protocols guided by WHO and CDC are in place to improve the practice of hand hygiene in healthcare.
Keywords: hand hygiene, nosocomial infections, evidence-based practice, research.

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In healthcare, most germs that produce infections are spread by contact of people’s hands. Hand hygiene protocols have been enforced upon bedside nurses for a long time since bedside nurses spend more time in direct patient care activities than any other health care providers and any other health care professional involved in direct patient care at the hospital setting(Fox et al., 2015). However, hand hygiene is a practice that all healthcare professionals should get involved in, and can save many lives.
Overview of Selected Evidenced-based Practice Project
Research and Evidence-Based Practice
Research and evidence-based practice are interrelated. Nowadays, research guides nursing practice and policies. Evidence-based practice derives from the combination of a body of nursing knowledge and research studies that are integrated into nursing practice. Both contribute to best practice nursing care that is evidence-based with a direct focus on quality patient care (Köhler, Landis, &Cortina, 2017).
Research methods are fundamental to the advancement and development of the nursing profession. It is through numerous research studies that nursing practice has revolutionized. Research studies help in the delivery of high quality, up-to-date nursing care that is safe, efficient and individualized.
Nursing Issue
The selected nursing issue is hand hygiene. In my experience as a bedside nurse, I have observed how many health care professionals do not follow proper hand hygiene protocols, mostly hand hygiene with soap and water. Following proper hand hygiene protocols can save lives. Microorganisms are mainly spread from healthcare professionals’ hands to patients. When we initiate nursing school, proper practice of hand hygiene and its importance is one of the first things we learn. Then, as classes’ level of difficulty increase, we might tend to forget how important it is to keep practicing hand hygiene; a simple but essential action. At work, nurses tend to concentrate on the tasks that are pending to be completed in such a rush, that hand hygiene compliance keeps falling behind. Several research studies have demonstrated the relationship between proper hand hygiene and the development of nosocomial infections. As demonstrated by research, hand hygiene is an essential nursing issue in need of attention and improvement.
Application to Selected MSN Program Specialty Track
The MSN specialty track I chose is family nurse practitioner (FNP). The selected area of interest is consistent not only with my current position as a bedside nurse but also with my selected MSN program track as an FNP. Hand hygiene is an essential part of health and healthcare, and I will still be involved in the direct patient care and keep practicing hand hygiene as an FNP.
Hand hygiene is an essential measure of infection control. In healthcare, most germs that produce infections are spread by contact of people’s hands. Studies show that on average, healthcare providers disinfect their hands less than half of the times they should. Hence, this contributes to the spread of healthcare-associated infections that affecting 1 in 25 hospital patients daily. An FNP, as a healthcare provider in direct contact with patients, must use proper hand hygiene in order to prevent infections. Lack of compliance of health care providers with hand hygiene is an issue of vital importance that needs to be addressed (Centers for Disease Control and Prevention (CDC), 2017).

Nursing Issue and Supportive Evidence Regarding the Issue
According to Marques et al. (2017), hand hygiene is the process used to remove microorganisms from hands, either by using alcohol-based hand rub or by washing hands with plain or antiseptic soap. Even though the method of washing hands using soap and water has been found to be the most effective means of eliminating microorganisms from the hands, the use of alcohol-based hand rubs has been found to eliminate 99.99% microorganisms from hands when scrubbing for 20 to 30 seconds.
Poor hand hygiene can lead to nosocomial infections, also known as healthcare-associated infections. The most common nosocomial infections are urinary tract infection (UTI), pneumonia, gastroenteritis, and surgical site infections. Nosocomial infections can be detrimental to the health and well-being of patients affected. Numerous research studies have been conducted regarding this issue. Approximately, hundreds of millions of patients have been affected in one way or another by nosocomial infections worldwide on a yearly basis. These infections can lead to extended hospital stays, a serious illness that can result in long-term disabilities, and sometimes even death. Consequently, health care costs increase for the affected patients and their families; rising the health-care system’s financial burden at the same time (Sickbert-Bennett et al., 2016). Nosocomial infections can directly affect healthcare professionals involved in direct patient care, as these infections can be transmitted directly to the employees. Subsequently, everyone involved in health care (from policymakers to healthcare professionals) is directly or indirectly impacted by the issue.
A simple solution to this issue is the strict and consistent adherence to hand hygiene protocols set by CDC and World Health Organization (WHO). The lack of compliance among health-care providers is a worldwide problem. WHO initiated a “patient safety challenge” called “Clean Care is Safer Care”. The initiative focuses on enhancing the standards and practices of hand hygiene in healthcare. WHO established specific rules on when and how to complete hand hygiene depending on the scenario and the agent being used to clean the hands. It is important that all healthcare professionals are familiarized with the latest evidence-based practice material available on hand hygiene, and their facility of employment’s policies and protocols regarding this matter. The expectations are that the incidence of nosocomial infections decrease and together with this the related healthcare costs. In order to achieve this, there needs to be an increase in the number and frequency of healthcare professionals adhering to hand hygiene protocols (WHO, 2017).
Evidence-based Practice Question
In inpatient adults, how does nurses’ use of soap and water or alcohol-based hand sanitizer before and after patient contact compared to nurses’ lack of compliance with hand hygiene before and after patient contact affect the incidence of nosocomial infections within four weeks?
P-Inpatient adults (>18 years old)
I-Nurses’ use of soap and water or alcohol-based hand sanitizer before and after contact with patients
C-Compared to lack of compliance with hand hygiene before and after patient contact
O-Incidence of nosocomial infections (such as CLABSI, CAUTI, pneumonia, and gastrointestinal infections)
T-Four weeks

Research Literature Support
The purpose of a study by Teker et al. (2015) is to explore the factors and determinants associated with hand hygiene observance at a hospital. The researchers used a quasi-experimental approach with a pretest-posttest design. The subjects included 41 physicians, 114 nurses, 179 hospital staffs, and 35 assistant health personnel. For the pretest, the data was collected by measuring and recording the baseline hand hygiene adherence of the respondents. For the posttest, adherence was measured and recorded after training. The study concluded that the rate of hand hygiene adherence for trained doctors, nurses, and other staff members was higher when compared to their untrained colleagues. One strength of this research is that the study results can be transferred and used by other nations and hospitals. One limitation of the study is that as a quasi-experimental study, the researchers had less control over study conditions.
A research study by de Souza, Ramos, Becker, Meirelles, and Monteiro was published in 2015. The aim of the study was to discover hand hygiene adherence of nurse practitioners in intensive care units. This study is based on 793 observations from an institution in southern Brazil and had a quantitative approach. Secondary data was collected from a database in a health institution in southern Brazil. As part of the study results, adherence rate for hand washing was 43.7% overall, the physiotherapist’s adherence rate was the highest at 53.5%, and the lowest adherence was documented among the nurses at 29.2%. The study concludes that handwashing promotion and training should be increased. One strength of this study is its generalizability due to a large sample being used for the research. The study limitation is that no primary data was used.
The purpose of a study by Chatfield, Nolan, Crawford, and Hallam (2016) was to study and explain the results from a qualitative study that was conducted to explore hand hygiene effects among healthcare professions in hospitals, particularly nurses.Qualitative research was used, and the study investigated eight nurses in the United States. An interview was carried out and data were analyzed using interpretative phenomenological strategies. This study examined the perceptions of nurses towards hand hygiene on practical hygiene, trial, and risky business. The findings showed there is a conflict between how nurses perceive their own hygiene actions and how they sensed their organization management considered hygiene activities. One strength and advantage of the study is that it can be transmitted to other departments within hospitals. The study’s limitation is that it used a small sample size.
Sharif, Arbabisarjou, Balouchi, Ahmadidarrehsima, and Kashani (2016) conducted a study with the aim to explore the attitude, knowledge, and productivity of nurses regarding hand hygiene. This quantitative research used 200 nurses as study subjects from three health institutions in Kerman city. A standardized questionnaire was used to collect the data. The results revealed that most nurse practitioners (74.5%) have good knowledge, 70.5% have a positive attitude, and 87.5% have good performance regarding appropriate hand hygiene methods and compliance. Therefore, this study concluded that most nurses are conscious of the significance of hand hygiene. The study used a large sample, which is a strength. One study limitation is that standardized questionnaires were used, and these are associated with bias findings.
A research study was conducted by Fox et al. (2015)in a 27-bed adult cardiovascular medical ICU (intensive care unit) at Mission Hospital in California. The purpose of the study was to examine a new hand hygiene protocol designed to decrease the rate of nosocomial infections and increase nurses’ compliance towards hand-washing in ICU. This research was based on a pre-experimental design. All study data were collected from one ICU department from 2009 to 2012. Researchers compared 12-month rates of 2 common central catheter-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI), hospital-acquired infections (HAI), and the compliance rate of nurses towards hand-washing. Results were measured before and during the protocol’s implementation. Specific patient data such as sex, age, length of hospital stay, daily census, and severity of illness were collected in order to compare variables that might impact the rate of HAI. Although there was not a statistical significance in the rate of HAI, a reduction was reported in 12-month infection rates for CAUTI and CLABSI. There was also a reported improvement in nurse hand-washing compliance. A strength of this study is that the new protocol applied to the ICU can be applied and or tested in other units. A limitation is that the results have limited generalizability to other institutions or units. Also, pre-intervention results were compared with protocol results, which limit the confidence in the effect of the protocol. Higher than normal hand-washing rates for the nurses could be due to a Hawthorne effect since they were aware their hand hygiene rate was being observed.
In a study by Gerlich et al. in 2015 with the aim to investigate the importance of hospital hygiene in reducing nosocomial infections, qualitative and quantitative research methods of HARMONIC (Harmonized Approach to avert Multidrug-resistant Organisms and Nosocomial Infections) controlled intervention study was used. This study took place in eight acute care hospitals in the ‘Health Region Baltic Sea Coast’ in Germany. The study was conducted for 18 months, including six months of follow-up to study quality of life of the study participants after discharge from the hospital. Although data was mainly obtained by documentation sheets and paper-based questionnaires, a documentation system with computer-assisted workflow was developed for support. The study demonstrated that 66% of the infections found in studied patients were acquired during their hospital stay, and most of the infections were found to be caused by MDROs (multidrug-resistant organisms). It was demonstrated that meeting the statutory requirements of hand hygiene can help reduce hospital-acquired infections. This study’s strength is that other regions can benefit from the findings on the implementation of the processes and structure for the management of MDROs. The study had the limitation of not being able to provide direct financial support to the hospitals to support the additional costs of the implementation of the program. Therefore, some aspects related to the current documentation of the hospital had to fall back.
In a study by Gurieva, Bootsma, and Bonten (2012), the control of the spread of nosocomial infections through the use of patient’s isolation versus decolonization of patients and healthcare workers (HCWs) is analyzed. For this study, a mathematical model approach and stochastic simulation model was used. A computer simulation model was used to quantify the effects of antimicrobial treatment of carriage and patient isolation for HCWs and patients. The study reveals that HCWs may be persistently colonized with MRSA in the hospital setting and become a persistent source of spread of microorganisms; and that HCWs’ hands can be the main source of contamination for patients. According to this study, hand hygiene is important but decolonization strategies are key to preventing hospital-acquired infections. This study warns against decolonization of carriage between nurses and patients and offers suggestions for control that can be applied to other facilities. The model used presents the limitation of being a simplification of reality and not applying to all cases.
Sickbert-Bennett et al. (2016) conducted a study to investigate the relationship between an improvement in hand hygiene compliance and decreased incidence of nosocomial infections. The researchers used a multidisciplinary and practical approach for the management of HAIs. HAI rates and overall longitudinal hand hygiene compliance rates during the new program were studied by the use of generalized linear models. Data was being collected while observations were being made. Observations examining the new hygiene program exceeded 140,000. As a result of the new program, hand hygiene compliance increased while the rate of HAI considerably decreased. This study has great value for the use of other facilities since it is clinically applicable and scientifically authoritative. Due to deficient control over study conditions, modification of subjects’ behaviors could lead to misleading results.
A study by Nicholson et al. in 2016 was conducted with the purpose of determining the compliance level and the factors that could affect the compliance among HCWs’ hand hygiene practices. The study took place at a hospital in Kingston, Jamaica. This is a non-experimental study and nonprobability was used to choose the subjects. Subjects’ hand hygiene habits were observed by trained observers during two weeks in the areas of ICU, med-surge, and outpatient surgery. Observers’ identities were hidden to avoid influencing and or affecting HCWs’ behaviors towards hand hygiene practices. Infrastructure survey was done, and all data obtained was entered and analyzed in a Windows computer system of Chi-square analysis using Pearson’s formula. As a result, the compliance rate was 38.9% including all HCWs observed. No significant difference was observed between the hand hygiene habits of HCWs. Also, it was concluded that HCWs tend to comply more with hand hygiene after patient care rather than before physical contact with patients. Even though HCWs were aware that a study was being conducted regarding their hand hygiene habits and compliance, the identity of the observers was covert which allows for less influenced behavior on the subjects. Thus, the veracity of the results is higher. On the other hand, the researchers could not find a statistical difference in the compliance rate when comparing HCWs from different categories, since the sample size was not large enough.
Patel, Engelbrecht, McDonald, Morris, and Smythe published a research study in 2016 with the purpose of demonstrating an improvement in compliance with hand hygiene by using a multifaceted approach. The study design is a quasi-experimental pre-post intervention that used standardized interventions for the promotion of hand hygiene. Descriptive and analytical components were used for the study. Performance of the staff regarding compliance with the “five moments of hand hygiene” was assessed by using observation methods over a three-month period and standardized hand hygiene audit tools. Data were obtained from these tools and compliance was compared to the results from the previous year. All intervention wards showed improved compliance with hand hygiene during the study periods for pre and post patient contact. The surgical, maternity, and trauma wards showed the highest improvement among all. The post-intervention assessment also demonstrated an improvement when compared to the results from the previous year where no intervention was applied. This study showed to be successful in the improvement of hand hygiene compliance among hospital staff, and therefore the applied intervention can be used in other facilities as well. The study had limitations such as the choice of intervention wards may have selection bias. Also, it was not possible to ensure a stable sample size and randomization of the wards.
A research study was published by Lapão et al. in 2016 with the purpose of studying the use of gamification for the promotion of self-awareness and action of nurses towards hand hygiene practices. This is a qualitative study that used nonprobability sampling. The study took place in an ICU ward in Brazil. Researchers installed an automated monitoring system that helped collect real-time data. Such system was designed to detect and validate hand hygiene moments by detecting the specific location of nurses every time they entered a patient’s room. The processed information regarding nurses’ compliance with hand hygiene would be displayed anonymously on a screen. Each nurse would receive feedback regarding their performance via email by the end of the day. Feedback from nurses after the study revealed that they found the implementation to be helpful and a great opportunity to improve their compliance with hand hygiene. The intervention being tested proved to be effective in collecting valuable data in real time, creating awareness and promoting nurses’ hand hygiene compliance. The system has very accurate sensors that were installed strategically in different parts of each patient room (over the bed, over the sink, over the hand sanitizer dispenser) in order to capture real-time location for nurses. The system can be implemented in other departments and facilities for the same purpose. As a limitation, being a computer system that is monitoring nurses’ location, it could present technical issues that could lead to undesired side effects or errors in the data being collected.
Saddle-Rios and Aguilera conducted a study in 2017 with the aim of investigating nurses’ perceptions regarding causing factors of continuous low rates in compliance towards hand hygiene in their unit and what are their suggestions for improvement. Subjects (critical care nurses) were selected by non-probability sampling. This non-experimental study used the descriptive and exploratory survey to collect data. The responses from the survey were summarized and analyzed using descriptive statistics. The study results concluded that most surveyed nurses agree that understaffing and high workload contribute to low rates of hand hygiene compliance in the critical care unit. The study results can be generalized to a larger population. On the other hand, only nurses from a critical care unit were surveyed and therefore results may vary for other units. Another limitation of this study is that system-wide changes were taking place at the facility when the study took place, and thus nurses’ turnover rate was higher.
A proof-of-concept observational study by Mastrandrea, Soto-Aladro, Brouqui and Barrat (2015) was published with the purpose of studying how the combination of two automated infrastructures offers an improved understanding of the risks of microorganism’s transmission in the division. The study took place in an infectious disease unit at a hospital in France. Researchers collected specific data on 22 HCWs’ hand hygiene compliance and contact patterns while having them use wearable sensors. The close proximity between HCWs was recorded by means of a proximity-sensing platform. The study revealed that the majority of the visits took place during before noon; housekeeping staff and nurses’ aids representing the majority of the visits. Hand hygiene compliance rate, on its part, was found to be poor for all HCWs overall. The results of the study can be applied to a larger population, and therefore other facilities can benefit from the findings for future studies regarding the spread of hospital-acquired infections. The study had the limitation of possible inaccurate results due to behavior modification from HCWs being observed.
Huis et al. published a research study in 2013 with the purpose of evaluating the cost-effectiveness of two implementation strategies for the improvement of nurses’ compliance towards hand hygiene and thus the reduction of nosocomial infections. This quantitative study was implemented in 67 nursing wards in three Netherlands hospitals. Researchers used a cost-effectiveness analysis and a cluster randomized controlled trial for the study. Wards were randomly assigned to the experimental group or the control group. Researchers first collected baseline data before implementing the strategies. Trained nursing students in their last school year discreetly observed the subjects during the periods of data collection. Then, data collected was analyzed for cost-effectiveness. The study concluded that those wards influenced by the team and leaders-directed strategies had the highest increase in hand hygiene compliance rate (33%), while the wards with the state-of-the-art strategy (control group) have an increase of 24% in their hand hygiene compliance rate. The main strength of this study is that it used a comprehensive cost-effectiveness analysis in the perspective of a pragmatic randomized controlled trial. The scenarios used remain within the limitations of the literature’s estimates. Thus, ambiguity remains regarding the percentage of nosocomial infections that can be avoided by an improvement in nurses’ compliance towards hand hygiene.
Theoretical Framework
A conceptual model will be used to understand and explore research gap concerning nosocomial infections and hand hygiene. Regarding this conceptual model, Mody et al. (2011) explain that infections in skilled nursing facilities (SNFs) are common and lead to frequent hospital infections. For this project, therefore, this model will assist in recognizing the necessary actions, regulations, policy-makers, and support efforts to prevent or minimize infection rate (Mody et al., 2011). The project will depend on this theory to deliberate on behavior framework concerning the effects of hand hygiene on nosocomial infections. Teker et al. (2015) identify nosocomial infections as the common problems in most of the healthcare settings, and hand hygiene being the most efficient techniques for averting these infections. Chatfield et al. (2016) support earlier study findings with an emphasis that improvement in hand hygiene among nurses minimizes risks of healthcare-associated infections (HAIs).
The theoretical framework is useful to the selected PICOT since it gives guidance and directives for handling the PICO question. Its applicability is supported by the findings from empirical works. For example, Sharif et al. (2016) reiterate that proper hand hygiene minimizes nosocomial infections if it is practiced properly. In addition, hand hygiene is regarded as the most efficient technique to minimized HAI (de Souza et al., 2015). The conceptual model is about finding facts about the study subject.
Change Model
The change model that will be used in this project is Transtheoretical Model (TTM). TTM is an integrative framework used to understand the procedure of planned behavior transformation (Pro-Change Behavior Systems, Inc. 2017). Nurses must adopt behavioral change toward hand hygiene to reduce nosocomial infections cases in the hospitals. While other frameworks of behavior change concentrate only on particular aspects of change, the TTM integrate key aspects from other change models into an inclusive presumption of change suitable for different behaviors, groups, and environments (Pro-Change Behavior Systems, Inc. 2017).
The steps for change will include these five TTM stages. The first is pre-contemplation (not ready); nurses at this stage are not keen on taking action towards change within a six months period. They are mostly resistant, unenthusiastic, or unprepared for help (Pro-Change Behavior Systems, Inc. 2017). The project will identify a group of nurses who fall into this category and train them to change. The second stage is contemplation (Getting ready). Under this level, identified population intends to change in the next half-year period. They know the pros and cons of change (Pro-Change Behavior Systems, Inc. 2017). The third stage is preparation (Ready), which is about individuals who intend to take action instantaneously to achieve change (Pro-Change Behavior Systems, Inc. 2017). The fourth stage is action time. The group identified here has made detailed evident changes in their way of life within. Lastly, the maintenance stage is about individuals who have made explicit changes in their lifestyles, ready to prevent relapse, and apply the changes as requires (Pro-Change Behavior Systems, Inc. 2017).
This change model is relevant to the selected PICOT/PICO question because it will help to identify all the categories of nurses who need hand hygiene training. By using this change model, the project will scale its actions based on the different group requirements. Eventually, the advocacy will reach all the target groups with suitable message package.
Research Approach/Design
The research design will be quantitative involving randomized controlled trial and quasi-experimental approach that entails before-intervention-after and time series designs (Creswell, 2013). The randomized trial will entail division of the sample into intervention and control groups in a random manner; while the quasi-experiment design will entail natural division of the sample group for the purpose of random assignment of intervention. Randomized trials will provide the best scientific proof of the impacts of nurses washing hands before providing patient care. The quasi-experiment will provide some sort of real picture of the hand washing outcomes on the health status of the adult inpatients.
The chosen design is advantageous as it provides benefits of a high probability of presenting results of significance regarding the number of nosocomial infections in the periods before and after the intervention; thus establishing an appropriate statistical difference between the appropriate use of hand hygiene methods before and after patient contact versus noncompliance with such methods. There may be a potential for infection risk factors being varied in a population of patients in the two periods (before and after intervention) (Creswell, 2013). The study’s theory supports the belief that there will exist only a small number of nosocomial infections after the intervention; thus making the before and after intervention as well as the time series designs the best design choices for this research. Nevertheless, certain epidemiological pitfalls are often inherent in almost all study designs, for instance, short periods of follow up (24 hours), and measurement errors.
Sampling method
The research target population is inpatient adults who are 18 years and above. The research sample was selected through identification of one chosen hospital in Miami. The hospital was found through the database of American Hospital Association. A random sample of 10 beds for each unit was chosen from each strata group, to obtain a study sample of 80 adult inpatients.
The random stratified sampling is a probability sampling method that involves random selection of participants. The method entails setting appropriate procedures to ascertain that the diverse units in the population have equivalent probabilities of being selected (Levy &Lemeshow, 2013). The sampling method is advantageous in that it is a representation of the entire population that is being studied. A sample size of 80 inpatients will represent all the hospitals in the region of the study since it is characterized by minimal bias during sample selection by ensuring that all segments of the population are represented equally. By choosing patients from different departments it makes it easier to extend the results from a sample to a larger population. On the other hand, stratified random sampling has the disadvantage of being unusable in cases when the researchers are not able to confidently classify all population members into subgroups.
The research will be performed in an ethical manner through protection of the participants’ rights. The selected participants will review the trial protocol and guidelines before the beginning of the study, and sign consent forms that protect their privacy. The information collected from the participants will not be shared outside the study team and will remain anonymous. The study will also present data that proves to be medically vital in a responsible and scientific manner. The central ethical approach that will be employed in this study will include providing knowledge of the benefits as well as risks of involving in participation (Levy &Lemeshow, 2013). Confidentiality and anonymity principles will also protect the participants from public exposure.

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Data Collection Methodology
Information will be gathered from the target population. In this case, the target population comprises of 10 randomly selected bedside nurses in each inpatient unit in the chosen hospital. An amount of 40 randomly selected nurses per day will be observed and surveyed, given that the chosen hospital has two med-surge units, one ICU, and one maternity unit.Since bedside nurses work three days a week and their schedule varies on a weekly basis, the number of study subjects will be bigger than 40 and it is difficult to determine a fixed sample size. The main information of interest is hand hygiene compliance of nurses when delivering care to admitted clients. Preferably, the data collection would involve taking measurements of the hand hygiene adherence by nurses during patient care. It is worth noting that the collection of data on hand hygiene adherence requires the researcher to conduct observation and taking field notes. For this, the help of volunteers will be used for observation and data collection. Volunteers will also help to distribute questionnaires and collecting them back for analysis. An in-service would have to be provided to those volunteers assisting with the research study. Observation would allow making accurate measurements on the behaviors of interest in both intervention and control group. Additionally, measurements will be taken in the cases of nosocomial infections before and after the intervention.
Data Collection Points
Quantitative measurements that describe specific characteristics of the target population will be taken, which involves measuring nurses’ adherence to hand hygiene practices before and after handling patients in the inpatient adult facility. Data from the system will also be collected, using patient’s privacy protection methods, to determine the incidence and development of nosocomial infections during the study period. The study would consider two groups comprising of intervention and control group. Therefore, one med-surge unit and the maternity unit will be assigned to the control group; and the other med-surge unit and the ICU unit will be assigned to the intervention group. Ideally, information will be gathered from each group before and after the intervention. The control group will not receive any intervention. On the other hand, the intervention group will be observed for two weeks of pre-intervention, and then two weeks of post-intervention. The intervention will consist of assigning a leader in each unit that will teach, promote, and reinforce the hospital’s policy of hand hygiene and its compliance. It is imperative to understand those study participants would provide valuable data that illustrates the impact of nurses’ adherence to hand hygiene on nosocomial infections in the inpatient population. Additionally, the investigator would consider time series data for collecting sufficient evidence for completing the study.
Length of Time for Data Collection
The collection of data from the field requires longer period compared to collecting information from secondary sources. The research would involve collecting data from the primary source and would take four weeks. Specifically, follow-ups will be made in both intervention and control groups while collecting information at intervals of 12 hours per day. Therefore, day shift and night shift will be alternated daily for observation and data collection. For instance, data will be collected from the selected day shift nurses on day one, and night shift nurses on day two. Ideally, this allows the researcher to gather sufficient information that is relevant especially in the intervention group. Notably, the collection of data would be in two periods, that is, before and after the intervention. It is worth noting that nosocomial infections take approximately three to four days to develop hence need for a longer period of collecting data (Luangasanatip et al., 2015). On the other hand, the collection of the time series data from secondary sources takes shorter time of less than a day. Ideally, the time for collecting data varies with the sources of acquiring information.
Explanation Regarding Source of Data
Observation and questionnaire techniques will be used during the collection of primary data from the inpatient facility. Two methods involve developing structured questions in the questionnaire and giving all participants to fill them. Structured questions are necessary for collecting key information for completing the study. Questions will target areas such as frequency of hand hygiene, types of product used and why select one over the other, knowledge of hospital policy, motivating and discouraging factors, and knowledge on incidence and causal factors of most common nosocomial infections. On the other hand, extra information can be collected by using structured or systemic observation. The observation allows the researcher to collect vital data and avoid biased information because it involves collecting data without directly engaging the respondents.
Moreover, structured observation would allow making a comparison between data sets collected and determine their consistency. Additionally, it takes a short time to collect the data when using observation. Evidently, the use of a questionnaire and structured observation would be appropriate for collecting primary data from the field.
Fostering Data Quality
The quality of data in research is vital in making a valid and reliable conclusion about the population under study. Therefore, the study would foster the quality of data collected through establishing standardized measures of collecting and recording the information from the respondents hence minimizing human errors (Kush & Goldman, 2014). Human errors have negative impacts on the quality of data. Hence, effective methods of collecting and recording the data will be used. The data would undergo screening for accuracy before feeding to the database. Similarly, the data coding process would be systematic with the reliable system. Moreover, the process will be double-checked to ensure correct entry and coding of the data.
Analysis
Descriptive Analysis
Descriptive statistics is an imperative technique in quantitative data analysis because it aims at summarizing the massive data collected for quantitative research. Ideally, the study would employ the measure of central tendency for descriptive analysis. Specifically, the mean will be used as the measure of central tendency. The mean provides a summary of the massive data and is simple to calculate and interpret (Cope, 2015). For example, I will compute the average of nurses’ adherence to hand hygiene and show its impact on the occurrence of nosocomial infections among inpatient adults. Therefore, using the measure of central tendency in this study would enable the researcher to summarize data in a manageable form that is easy to interpret.
Bivariate Statistics
The bivariate analysis involves the analysis of two variables to determine the empirical relationship between them. Bivariate statistics to use would be correlation and t-test. The correlation in quantitative data analysis enables the researchers to evaluate the relationship between two variables. Ideally, the variables of interest include nurses’ adherence to hand hygiene prior and post contact with patients and the occurrence of nosocomial infections in inpatient adults. Correlation is an imperative analysis tool for analyzing the relationship between the two variables. The correlation statistic is easy to compute as well as interpreting the findings hence an effective tool for analysis (Cope, 2015).
Furthermore, the study would consider two sets of data, that is, data before intervention and data after the intervention. The t-test is an appropriate inferential technique for assessing the empirical relationship between the two sets of data. The inferential test helps the researcher in testing hypotheses and making conclusions based on scientific evidence. The t-test would involve comparing the means of the two data sets to determine the significant difference before and after the intervention. Expectedly, it is hoped to find a significant difference in the occurrence of nosocomial infections between the intervention and control group. Conducting an inferential analysis enables to make conclusions based on scientific evidence. Additionally, recommendations will be made concerning the results to the healthcare facilities. For instance, it could be recommended that nurses should adhere to hand hygiene policies when caring for inpatient adults to reduce the incidents of nosocomial infections. Moreover, the study findings could be generalized to the larger population after the analysis given they are valid and reliable.
Solution Impact
Hand washing and disinfection are such important procedures and cannot only be talked about by they need to be implemented. W.H.O projects that by the year 2020, the health worker will have adopted hand hygiene as a number one measure for prevention of nosocomial infection among those patients at risk. To implement this nursing practice issue, the following will be done:
The first step will involve the change of the current operating system that has proved infective in facilitating hand hygiene. This will involve the provision of the necessary infrastructure such as piped water, soap, and alcohol-based hand rubs. Continuous safe water supply and hand rubs should be readily available to encourage.
Secondly, regular training should be offered to nurses to keep them on track on this practice issue. The training entails the procedure of hand washing and the 5 movements of hand hygiene which are ensuring that nurses wash their hands before touching the patient, before carrying out any aseptic procedure, after a nurse touches a patient, after touching what surrounds the patient, and when a nurse becomes in contact with body fluids. Education should also include provision of educational prompt materials such as charts that will act as reminders for quick intervention
Evaluation of the nursing issue will be based on the measuring indicators which depict improvements. The first indicator is the increased consumption of soap and hand rubs increased compliance to the use of the 5 movements of hand hygiene, improved infrastructure and improved perception which can be assessed by the use of a questionnaire and a decreased number of cases of nosocomial infections. The stakeholders will experience a reduced workload as a result of a decreased.
Translation of Results
The vision this practice issue is to turn hand hygiene into an organizational culture or a habit within one year. This can be achieved through explaining to nurses and other health workers on the benefits of hand hygiene. Different people respond differently to an intervention. One of the challenges that I will face in this study is resistance from nurses to adapt the procedure. This resistance will be more pronounced in cases of late adopters. This problem can be overcome by explaining to nurses how the proposed practice issue will benefit the for example in the reduction of workload. Nurses are more likely to embrace an intervention if the information will benefit them.
For this intervention to be effective, resources are necessary. From this piece of research, infrastructures such as water pumping systems, Soap and a hand rub. Piping system will ensure that there is a continuous supply of clean water for hand washing and soap and hand rub are supplies required for carrying out the procedure.
Conclusion
The above literature review indicates that hand washing and disinfection reduces 40% of the nosocomial infection. This research will add more knowledge on why this has not happened despite the presence of information among nurses on the importance of hand washing and disinfection; nurses are at one moment or another failing to carry out hand washing or disinfection. The research identifies the gaps which exist in the implementation of the procedure and finds out ways of working on the challenges that nurses do face while carrying out their duties. Training of nurses has been identified as a major area that improves the effectiveness of hand washing procedure. The research highlights any significant differences that exist between trained and untrained nurses in the prevention of nosocomial infections. The reduction in nosocomial infection will help improve quality of services offered to patients as a result of decreased workload on nurses, reduction of the disease burden by the reduction of a number of days spent in hospitals due to hospitalization. This will have a direct positive impact on the amount of money spent by community members, friends and relatives and family members for the management of patients with nosocomial infection.

References
Appendix A
Citation Purpose of the research Research Design and Sample Data Collection Methods Results
Teker, B., Ogutlu, A., Gozdas, H. T., Ruayercan, S., Hacialioglu, G., &Karabay, O. (2015). Factors affecting hand hygiene adherence at a private hospital in Turkey. The Eurasian Journal of Medicine, 47, 208-212.
Permalink:
http://www.eajm.org/eng/listele/makale-listele The aim of the study is to explore the factors and determinants associated with hand hygiene observance at a hospital A quasi-experiment: pretest-posttest design
N=41 physicians, 114 nurses, 179 hospital staffs, and 35 assistant health personnel

Pretest: baseline hand hygiene adherence of the respondents was measured and recorded
Posttest: after training the adherence was also measured and recorded Hand hygiene adherence rate of trained doctors, nurses, and other staff members was higher compared to their untrained counterparts at a ratio of [48% (35/73) vs. 82% (92/113), and [63% (50/79) vs. 76% (37/49), respectively.
The article concludes that hand hygiene training is one of the most important ways of preventing nosocomial infections
de Souza, L. M., Ramos, M. F., Becker, E. S. D-S., Meirelles, L. C. D-S., &
Monteiro, S. A. O. (2015).Adherence to the five moments for hand hygiene among intensive care professionals. RevistaGaúcha de Enfermagen, 36(4), 21-28.
Permalink: http://ref.scielo.org/r6m2yg
The purpose of the study was to discover the hand hygiene adherence of nursing practitioner in intensive care unit quantitative approach
N= 793 observations from an institution in southern Brazil Collecting secondary data from a database of a health institution in southern Brazil Adherence rate for hand washing was 43.7% with the physiotherapists being the adherent group at 53.5%, but the lowest adherence was recorded among the nurses at 29.2%. The study indicates that hand washing advocacy and training should be increased.
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.
Permalink:
http://journals.sagepub.com/doi/full/10.1177/2050312116675098

The purpose of this article is to investigate and explain results from a qualitative study that was carried out to explore hand hygiene effects among healthcare professions, particularly nurses, in hospitals. qualitative research
N= 8 nurses in the United States Carried out a qualitative interview and analyzed through interpretative phenomenological strategies The study explored the perceptions of nurses towards hygiene on trial, risky business, and practical hygiene. The findings showed the conflict between how nurses consider their own hygiene actions and how they felt organization management considered hygiene actions.
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), 57-65.
Permalink:
http://www.ccsenet.org/journal/index.php/gjhs/article/view/53081/29836
The study aim was to
explore knowledge, attitude, and productivity of nurses concerning hand hygiene
Quantitative research
N= 200 nurses from three health institutions in Kerman city The data were collected using standardized questionnaire. The findings showed that most of the nursing practitioners (74.5%) have good knowledge 70.5% have a positive attitude, and 87.5% have good performance. The study shows that most
of the nurses are aware of the importance of hand hygiene.
Kampt, G. Loffler, H. Gastemeier, P. (2012)
Hand Hygiene for the Prevention of Nosocomial Infections. Journal of US National Library of Medicine, 106(40): 649–655. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2770229/ The goal is to establish hand disinfection as a decisive quality parameter anchored firmly in clinical routine. The study used a systemic review Review of available literature by a systemic review of available literature Disinfection reduces destruction of cutaneous layer of the skin hence should be used unless the hands are physically soiled or one comes in contact with spore-forming organism such as difficile

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