Hand hygiene

JBI Database of Systematic Reviews & Implementation Reports 2014;(12)1 318 - 337

doi: 10.11124/jbisrir-2013-1378 Page 318

Compliance to hand hygiene practice among nurses in Jimma University Specialized Hospital in Ethiopia: a best practice implementation project

Garumma Tolu Feyissa1

Judith Streak Gomersall2

Suzanne Robertson-Malt2

1. Jimma University, College of Public Health and Medical Sciences, Department of Health Education and

Behavioral Sciences, Ethiopia

2. School of Translational Science, Joanna Briggs Institute, University of Adelaide, South Australia

Primary contact:

Garumma Tolu Feyissa,

Work e-mail: [email protected]

Key dates:

Commencement date: May 1, 2013,

Completion date: September 27, 2013

Executive summary

Background

Hand hygiene practice reduces cross-contamination and infection, and it makes sense from a

resource saving perspective. The hospital costs associated with a reduction of four or five Health

Care Associated Infections may equal the entire annual budget for hand hygiene products.

Objective

The objective of this best practice implementation project was to promote evidence informed best

practice of hand hygiene among nurses in Jimma University Specialized Hospital Out Patient

Department.

mailto:[email protected]


doi: 10.11124/jbisrir-2013-1378 Page 319

Methods

An inter-professional project team conducted baseline and post implementation audits using the

Joanna Briggs Institute Practical Application of Evidence System. Using six audit criteria, 163

hand hygiene opportunities were observed for both a baseline and follow-up audit. Seven nurses

were interviewed for the seventh criteria.

Results

The baseline audit revealed a compliance of 2% for using an effective hand washing technique

involving three stages, and 4% for washing hands that were visibly soiled with liquid soap and

water. Post implementation audit showed an average of 80% improvement in compliance to the

evidence based audit criteria for effective hand hygiene.

Conclusions

This project showed that role modeling, posting reminders about hand hygiene procedures and

presenting evidence summaries to the clinical teams were strategies that resulted in improved

adherence to best available evidence for hand hygiene. Involving key stakeholders in identifying

the strategies to change practice is essential for the realization of the implementation of effective

hand hygiene. A regular program of random audits conducted by an inter-professional team can

help to achieve sustainable compliance to effective hand hygiene.

Keywords

audit, best practice, hand hygiene, nurses, medical outpatient department, implementation project

Background

Health care associated infections (HCAI’s) are significant causes of morbidity and mortality worldwide.1

Transmission of health care associated pathogens most often occurs via the contaminated hands of

health care workers (HCW’s) and other environmental sources.2 Some pathogenic organisms may

become ‘resident’ flora on HCW hands. Inadequate hand cleansing enables the growth of this ‘resident’

flora and the subsequent cross-transmission .3 The role of contaminated HCWs’ hands in the

transmission of health care associated pathogens, has been confirmed by numerous investigations.4,5,6

Effective hand hygiene practice is considered to be one of the most important infection control measures

for preventing health care associated infections.4,7

Hand hygiene is defined by the World Health

Organization (WHO) as any action of hand cleansing. Hand hygiene is performed using the application of

either non-antimicrobial or antimicrobial soap/solution and water, or waterless antimicrobial agent to the

surface of the hands. The techniques used vary depending on the product used, as well as the purpose of

performing hand hygiene.7 There are five moments of hand hygiene: 1.before touching a patient, 2. after

touching a patient, 3. before performing a clean/aseptic procedure, 4. after touching the patient

surroundings, 5.after body fluid exposure risk.2

Research has established that improving hand hygiene practice reduces cross-contamination and

infection. A study conducted in Victoria, Australia demonstrated that the incidence of Methicillin Resistant

Staphylococcus Aureus (MRSA) was significantly decreased after the implementation of a hand hygiene


doi: 10.11124/jbisrir-2013-1378 Page 320

program.9 In addition; two reviews of the evidence on the effects of hand hygiene have concluded that

improved compliance with hand washing was associated with a significant decrease in overall rates of

hospital acquired infections.5

Research has also shown that best practice hand hygiene makes sense from an economic/fiscal

perspective, which is particularly important in a low income country like Ethiopia. The hospital costs

associated with only four or five HCAIs of average severity may equal the entire annual budget for hand

hygiene products used in inpatient care areas. Just one severe surgical site infection, lower respiratory

infection, or bloodstream infection can also result in incalculable physical and emotional cost to the

patient and family.8, 9

In Ethiopia, as in many other low income countries, compliance of healthcare workers (HCWs) with the

recommended hand hygiene procedures is generally poor. Estimates of compliance suggest that

compliance rates are generally below 50%.1

Research has established that in some health care settings

in Ethiopia the compliance with recommended hand hygiene practice is even lower. A study conducted in

North Wollo Zone, Amhara Region in Ethiopia in 2006 found that out of the 1,021 hand washing

opportunities observed; only 296 (28.9% ± SD 27.31%) opportunities were in line with effective hand

hygiene practice.10

There is clearly a need to enhance hygiene practice in Ethiopia, and to promote best practice hand

hygiene practices. To date, the JBI method of evidence implementation has not been undertaken in

Ethiopia, including the Jimma University Specialized Hospital (JUSH).1

Concern about poor hand hygiene practice in Ethiopia and the implications of this for the patient’s

wellbeing and fiscal burden were the motivation behind undertaking a best practice implementation

project. The aim of this project was to promote best practice hand hygiene practice in JUSH in the

Outpatient Department (OPD). By implementing an effective hand hygiene practice program within the

hospital, the author hoped to make a contribution to preventing both healthcare workers and patients from

getting hospital acquired infections that may lead to preventable deaths and unnecessary excess medical

costs.

The Evidence Base

The audit criteria used in the project were based on a JBI evidence summary that defines the key

features of best practice in hand hygiene. The JBI evidence summary states that the following are the key

features of best practice hand hygiene in the health care setting: 6,7,11,12,13,14

1. Practice effective hand decontamination immediately before each episode of direct patient contact

and immediately after any activity or contact that potentially results in hands being contaminated.6,7

(Level III)

2. Overall, there is no compelling evidence to favor the general use of antiseptic hand-washing agents

over soap, or one antiseptic over another.6 (Level III)

3. Reduction of both transient microorganisms and substantial reduction in resident flora occurs with

alcohol-based hand-rubs, but alcohol is not effective against some microorganisms such as


doi: 10.11124/jbisrir-2013-1378 Page 321

Clostridium difficile; will not remove dirt and some organic material; and may not be effective in

some outbreak situations. 6

(Level III)

4. Acceptability is based on the ease of use of a preparation, the ease of access to it and any

dermatological effects. Therefore, when hands are not grossly soiled, alcohol-based hand-rubs are

recommended for routine use. 1,11

(Level III)

5. If hands are visibly dirty, contaminated with proteinaceous material, have been exposed to blood or

other body fluids, or there is suspected or proven exposure to spore-forming organisms, hands

should be washed with soap and water. 2,11

(Level III)

6. Repeated exposure to hot water may also increase the risk of dermatitis, therefore avoid using hot

water. 7

(Level III)

7. Irritation occurred more frequently with the use of soap and less frequently with alcohol-based hand-

rubs. 1

(Level II)

8. HCWs should be provided with emollient hand creams or lotions to maintain skin integrity and

prevent skin irritation. 7,11

(Level II)

9. HCWs should pay particular attention to adequate drying of hands once washed to maintain skin

integrity. 6

(Level IV)

10. Education program for HCWs should include information regarding hand-care practices to reduce

the risk of skin damage from irritant contact dermatitis.7 (Level III)

11. Feedback of the results of audits of hand hygiene resources and individual hand hygiene practices

should be given to healthcare workers. 7,11

(Level II)

This evidence summary was based on a structured search of the literature and selected evidence-based

health care databases.6,7,11,12,13,14

The evidence suggested that the following, known as the three Rs are

part of evidence based best practice hand hygiene among HCWs in health care settings:

1. the right moment

2. the right procedure

3. the right choice of decontaminants

The Clinical Setting

Jimma University Specialized Hospital (JUSH) is one of the oldest public hospitals in Ethiopia. It was

established in 1938. Geographically, it is located in Jimma city, 352 km southwest of Addis Ababa. After

transfer of its ownership to Jimma University, the university has undertaken renovation and expansion

work to make the hospital conducive for service, teaching, and research. Currently, it is the only teaching

and referral hospital in the southwestern part of the country. It runs an annual governmental budget of

25.06 million Birr (one Birr: 18.89 USD) with a bed capacity of 450, and 750 combined clinical and

administrative staff. JUSH provides services for approximately 9000 inpatient and 80000 outpatient

attendances a year from a catchment population of approximately 15000 million people.15

The services

provided by the hospital include: Clinical (Med/Surg), Radiology, Laboratory and Pharmacy services.16


doi: 10.11124/jbisrir-2013-1378 Page 322

This evidence implementation project was undertaken as part of the author’s participation in the JBI

Clinical Fellowship Program, funded by an AUSAID initiative. The leader of the project works in Jimma

University as a lecturer of Health Promotion/Health Education.

Objective

The objective of this best practice implementation project was to implement evidence best practice hand

hygiene among nurses in JUSH Outpatient Department (OPD).

Methods

The project followed the JBI method of Implementation Science which is a team based program.

Methicillin Resistant Staphylococcus of audit re-audit using evidence based criteria and a constructive,

team based analysis of the organizational barriers and identification of strategies to overcome these

barriers. The JBI PACES – the Practical Application of Clinical Evidence System software is a core tool

used to guide this method of implementation. JBI PACES is an online tool that facilitates a project team’s

program of audits in small or large healthcare settings. PACES has been designed to facilitate audits

being used to promote evidence-informed health practice and includes a Getting Research into Practice

(GRiP) framework that may be used to help identify factors underpinning gaps between practice and best

practice strategies to overcome them. The project activities, best described as three distinct but

interrelated phases of activity are described below.

Phase 1: Design of evidence based audit criteria, team engagement and baseline audit

Firstly, permission was sought from Jimma University College of Public Health and Medical Sciences and

the hospital administration to conduct the project. Formal ethical approval was not needed. However, a

request was made to keep the information provided by each participant during the project confidential.

Following the completion of the training provided by the Joanna Briggs Institute (JBI), the team leader

identified key stakeholders in the organization to become members of the implementation project team.

The project team consisted of

1. Garumma Tolu Feyissa: team leader. He was responsible for conducting the baseline and post

implementation audit, analyzing and reporting the findings at each phase, and overseeing the

overall implementation of the project.

2. Dr. Essayas Kebede: Clinical Director. He was responsible for making relevant administrative

actions to correct barriers regarding human resources.

3. Mr. KoraTushune. His role was to ensure timely allocation of budget for the sustainability of the

project.

4. Mr. Feyera Gebissa: administrator of JUSH. He was responsible for taking relevant administrative

actions to correct barriers regarding human resources.

5. Dr. Daniel Yilma: Infection Prevention and Patient Safety (IPPS) Core Person. He was

responsible to oversee the technical aspects of the project and to fill skill gaps through training.

6. Mr. Gugsa Nemera: Nursing Director at JUSH and a lecturer in the Department of Nursing,

oversaw the technical aspect of the project,


doi: 10.11124/jbisrir-2013-1378 Page 323

acted as a role model for other staff in practicing hand hygiene, and

worked to fill the skill gaps of the nurses through training.

7. Mr. Alemayehu Mekuria: Coordinator of OPD in JUSH and a member of medical OPD nurses.

overseeing the technical aspect of the project,

supply of hand hygiene products to the point of care,

staff assignment at the point of care, and

being a role model.

8 Mr. Guluma Daba: JUSH Pharmacy Department Head and a member of JUSH Quality Control,

ensured that hand hygiene products were delivered in a timely manner.

9 Ms. Rahel Amare: Environmental health expert and an IPPS member of JUSH checked the OPD

was equipped with the necessary facilities.

The project team leader gave an orientation to the team members about effective hand hygiene practices

identified in the JBI PACES criteria.

Based on the evidence summary, the following seven audit criteria for effective hand hygiene practice

were developed for use in the baseline and follow up audit.

Criterion 1: Alcohol-based hand rubs are routinely used for hand hygiene unless hands are visibly soiled.

Criterion 2: Hands are decontaminated immediately after contact with individual patient contact and/or all

inanimate objects including equipment.

Criterion 3: Hands are decontaminated immediately before each episode of direct patient contact or

care, and/or all inanimate objects including equipment.

Criterion 4: Hands are decontaminated with an alcohol-based hand rub (unless hands are visibly soiled)

between different care activities for the same patient.

Criterion 5: Hands are washed using an effective hand washing technique involving three stages.

Criterion 6: Hands that are visibly soiled, or potentially grossly contaminated with dirt or organic material,

are washed with liquid soap and water

Criterion 7: Staff have received education about hand hygiene.

The criteria cover the four aspects of hand hygiene namely, when to perform hand hygiene (criteria 2, 3

and 4), what to use for hand hygiene (criteria 1 and 6), how to perform hand hygiene (criterion 5), and

education about hand hygiene (criterion 7).

The third activity in Phase 1 involved undertaking a baseline audit to assess the gaps between actual

hand hygiene practice and evidence based hand hygiene practice (i.e. best practice). The hand hygiene

practices of registered nurses were assessed using the seven criteria of effective hand hygiene practice.

We calculated the sample size using Open-Epi software package using hypothesized percentage

frequency of outcome factor in the population (P) of 28.90%, (taken from previous study10

), 95%

confidence interval (CI), and a margin of error of 5% with a two-week OPD patient flow of 333 visits.


doi: 10.11124/jbisrir-2013-1378 Page 324

This gave us a sample size of 163 hand hygiene observations for criteria 1-6. Observational data was

collected to determine compliance with the six audit criteria of effective hand hygiene and collated using

the JBI-PACES software. For the seventh criteria, we audited seven registered nurses working at medical

OPD. This criterion does not specify the range of time within which the staff nurse was trained. For our

purposes, we considered it as “Staff have ever received education about hand hygiene.”

Though informed consent was obtained from each nurse, the nursing staff were not informed of the

specific procedure for which they were being observed. Two masters students were hired to collect data

through participant observation. The project leader oriented them on the principles of evidence based

hand hygiene techniques, as well as how to determine compliance with each of the six audit criteria. The

students observed 163 hand hygiene opportunities during the data collection period (from May 1-15,

2013) while practicing at the OPD.

In order to implement this project, there should be an enabling environment. Therefore, in addition to the

above assessment, we assessed the availability of resources for the implementation of best hand

hygiene. We developed the facility assessment tool based on the required equipment detailed in the JBI

evidence summary. Our intention as a project team was to ‘scale up’ the program throughout other OPD’s

and other sections of the hospital. Therefore, the facility assessment included 21 OPD’s.

The project duration was a total of 8 weeks (July 13 to September 13, 2013)

Phase Two: Implementation of Best Practice

The project team discussed the results of the baseline data. We then explored the possible barriers to

the practice of effective hand hygiene. We identified some of the barriers during our team members’

meeting, and elicited other barriers from the nurses working in the OPD’s. Based on the identified

barriers, we identified key strategies and subsequent actions. The discussion process was guided by the

PACES GRiP framework/tool. Based on the report from the GRiP analyses, we sought resources

(technical, logistic, or financial) from the relevant stakeholders. The barriers, strategies and resources

identified by the team are presented in the results and Appendix1.

In order to increase compliance through changing the behavior of the nursing staff, we combined domains

of multiple theories as follows.

1. Social Learning theory (demonstration, observation, and direct instruction).17

2. Social influence theory18

(commitment to team members, norm): the head of OPD, the Nursing

Director and other nursing leaders were role models for best practice hand hygiene techniques.

3. Theory on team effectiveness19,20

: Team members were encouraged to address each other

when they witnessed missed hand hygiene moments.

4. Leadership theories21

(for staff motivation and enhancing commitment): In order to increase the

motivation of nurses to perform effective hand hygiene, we gave recognition to the nurses’

compliance to hand hygiene through establishing Nurses’ Champion Group for effective hand

hygiene.


doi: 10.11124/jbisrir-2013-1378 Page 325

Phase 3: Post implementation Audit

In the follow up audit, we used the JBI PACES tool for data collection. Data were collected for 163 hand

hygiene opportunities in the same method as the baseline audit.

Results

Phase 1: Baseline audit

The results of the baseline assessment indicated that the barriers to performing effective hand hygiene

implementation might be a gap in staff education, as well as adequate supplies and facility engineering.

Results are described in Table 1.

Compliance to effective hand hygiene was lowest for criteria 5 (Hands are washed using an effective

hand washing technique involving three stages) and criteria 6 (Hands that are visibly soiled, or potentially

grossly contaminated with dirt or organic material, are washed with liquid soap and water), with 2% and

4% compliance rates respectively. Compliance was highest for criteria 2 (Hands are decontaminated

immediately after contact with individual patient contact and/or all inanimate objects including equipment).

The frequencies of the seven criteria of effective hand hygiene for baseline audit are displayed in Table 2.

The compliance rate for each criterion is indicated in Figure 1.


doi: 10.11124/jbisrir-2013-1378 Page 326

Table 1: Results of baseline facility assessment in Jimma University Specialized Hospital Outpatient

departments, May 2013.

Criterion Yes NA

1. Sinks are present in the immediate vicinity of point of career

18 (85.7%) 0

2. There is consistent supply of water 0 0

3. Liquid soaps (hand washing solution) are present in the immediate vicinity of point of care

0 0

4. Alcohol hand rubs are present 15 (71.4%) 0

5. Paper towels (for drying hands) are present in the immediate vicinity of point of care

0 0

6. Emollient hand cream is available 0 0

7. Glycerine or lotion is available 0 0

Table 2: Results of baseline audit in Jimma University Specialized Hospital, May 2013

Criterion Yes NA

1. Alcohol-based hand rubs are routinely used for hand hygiene unless hands are visibly soiled

40 (25.2%) 4

Hands are decontaminated immediately after contact with individual patient contact and/or all inanimate objects including equipment

93 (57.1%) 0

Hands are decontaminated immediately before each episode of direct patient contact or care, and/or all inanimate objects including equipment

13 (8.0%) 0

Hands are decontaminated with an alcohol-based hand rub (unless hands are visibly soiled) between different care activities for the same patient

13 (18.8%) 94

Hands are washed using an effective hand washing technique involving three stages.

4 (2.4%) 0

Hands that are visibly soiled, or potentially grossly contaminated with dirt or organic material, are washed with liquid soap and water

4 (4.3%) 69

Staff have received education about hand hygiene

2 (28.8%) 0


doi: 10.11124/jbisrir-2013-1378 Page 327

Phase Two: Implementation of Best Practice

The barriers, strategies and resources were identified by the key stakeholders as described in the

methods section. In general, the strategies were implemented over an eight week period in an attempt to

close the gaps found in the baseline audit. The strategies included:

1. Public posting of the poor results from the baseline audit.

2. Conversation with nursing staff to explore barriers.

3. Posting reminders and procedures for hand hygiene at the walls inside the OPD’s. Most (97.6%)

failed to follow the standard procedures. In addition, most of the nurses did not wash their hands

at the right moment, especially before patient contact (92.0%) and in between procedures

(81.2%). Therefore, we posted hand hygiene procedures and the following reminders on the

walls of the OPD’s:

4. “Help Prevent Infections Wash Your Hands with Soap and Water”, and

5. “The 5-moments for hand hygiene.” (1.before touching a patient, 2. after touching a patient, 3.

before a clean/aseptic procedure, 4. after touching the patient surroundings, 5.after body fluid

exposure risk) (Appendix 2).

6. Education through distribution of the Evidence Summary. We supplied all the seven nurses with a

hard copy of the JBI evidence summary on best practice hand hygiene.

7. Role-model / champion lead by example strategy.

8. Monitoring of team members.

9. Champion recognition strategy.

The Grip strategies and outcomes are described further in Appendix 1.

Phase 3: Post implementation Audit

In the follow-up audit 100% compliance rate was obtained for criteria 1, 2, 6 and 7. The compliance rate

was lowest for criteria 3 (Hands are decontaminated immediately before each episode of direct patient

Figure 1: Results of baseline audit of nurses’ compliance to effective hand hygiene at medical OPD

of Jimma University Specialized Hospital, Southwest Ethiopia, May 2013


doi: 10.11124/jbisrir-2013-1378 Page 328

contact or care, and/or all inanimate objects including equipment) with a compliance rate of 83%. The

observed frequencies for each criteria of post-implementation audit are displayed in Table 3.

Table 3: The result of post-implementation audit, Jimma University Specialized Hospital, Southwest

Ethiopia, September 2013

Criterion Yes NA

1. Alcohol-based hand rubs are routinely used for hand hygiene unless hands are visibly soiled

163(100%) 0

2. Hands are decontaminated immediately after contact with individual patient contact and/or all inanimate objects including equipment

163(100%)

0

3. Hands are decontaminated immediately before each episode of direct patient contact or care, and/or all inanimate objects including equipment

135(82.8%) 0

4. Hands are decontaminated with an alcohol-based hand rub (unless hands are visibly soiled) between different care activities for the same patient

107(95.6%)

51

5. Hands are washed using an effective hand washing technique involving three stages.

151(92.6%) 0

6. Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material are washed with liquid soap and water

51(100%) 112

7. Staff have received education about hand hygiene

7(100%) 0

We saw marked change in compliance following the implementation of strategies to overcome the

identified barriers. Figure 2 shows the percentage compliance for each of the audit criteria in the follow up

audit compared to that found in the baseline audit.


doi: 10.11124/jbisrir-2013-1378 Page 329

Figure 2: Baseline versus post audit comparison of compliance to effective hand hygiene among nurses

in medical OPD of Jimma University Specialized Hospital, Southwest Ethiopia, September 2013

Discussion

The baseline audit indicated that nurses were not adhering to the basic principles of hand hygiene and

they were not choosing the right decontaminants. While they should have washed hands visibly soiled

with organic matter with soap and water, they often used alcohol hand rub instead.

The evidence implementation project was a success in that improvements were observed across all of

the evidence based audit criteria ranging from 43% to 96%. The post implementation audit showed a

hundred-percent compliance for criteria 1, 2, 6, and 7. For criteria 3, 4 and 5, the compliance was 83%,

96%, and 93% respectively.

The shortage of hand hygiene products and inconsistent supply of water were the barriers identified

during the facility assessment. Utilizing the information obtained from the facility assessment, we ensured

continuous supply of hand hygiene products and water. This has resulted in an ‘enabling’ environment for

the hand hygiene practice.

Other barriers identified included the skill and knowledge gap, misperception and negligence. In this

regard also, the strategies utilized to tackle the barriers were effective in increasing compliance. For

example, the project team’s use of various change management theories contributed to their identification

of barriers to the evidence and strategies to overcome these barriers. One clustered randomized trial

demonstrated that in the long run, domains of the components of social influence theory, and leadership

theory correlated positively with changes in nurses’ hand hygiene compliance. The trial also showed that

in the short term, changes in nurses’ hand hygiene compliance were positively correlated with

experienced feedback about their hand hygiene performance.22


doi: 10.11124/jbisrir-2013-1378 Page 330

In addition, we obtained significant change in compliance to effective hand hygiene by providing

education to the nurses, and correcting some misperceptions. For example, informing the nurses that

alcohol hand rub is not effective in removing organic materials, and of the importance of adhering to the

steps related to the ‘five moments of hand hygiene’.2 The education provided to the nurses through

posters, demonstrations, and through presenting evidence such as the JBI evidence summary appeared

to support their adherence to effective hand hygiene. Norm setting, and identification of the incorrect

practice of one’s colleague, has also contributed much towards the improvement of the compliance to

effective hand hygiene.

Although the post implementation audit showed a considerable change, in 12 of the 163 observations,

nurses missed one of the three steps for effective hand washing. Hence, future implementation projects

should emphasize the importance of adhering to the steps recommended (preparation, washing and

drying) and specifically, issues such as removing jewellery and keeping fingernails short.

In addition, the post implementation result indicated that the nurses overlooked the importance of hand

hygiene between each care activity for the same patient and before procedures in five of the 107, and in

28 of the 163 hand-hygiene observation opportunities respectively. This raises the importance of future

education / awareness about the five moments of hand hygiene.2

The result of this best practice

implementation project was communicated to the team members, who have a say regarding decision

making in the hospital affairs. In addition, the result was presented to the JBI as part of the completion of

the clinical fellowship program.

Sustainability

Whilst the project was a success, and made a contribution to improving health outcomes in the setting in

which it was conducted, it needs to be noted that it was small-scale. The small scale of the project may

explain why the project was relatively easy to implement and its successful outcomes in terms of

improvements in hygiene practice.

It is important to up-scale the project and to ensure that the changes in hand hygiene practice at the

facility are sustained over time. Towards this end, follow up audits will need to be undertaken and barriers

to best practice continually identified and addressed, including the review of the strategies already

identified and implemented in this project. It is also essential to focus on creating an enabling

environment, which raises the importance of ensuring continuous supply of hand hygiene products and

water.

The current experience indicated that involving relevant stakeholders and people who are directly

connected to the project is key for implementing the evidence into practice. Due to the high caseload,

efforts are needed to carefully embed the strategies identified in this project into the everyday systems

and processes of care. Unless continuous reinforcement strategies are set, it will be very difficult to

ensure sustainability. In this regard, recognition of the good practice of nurses, by establishing nurse

champions for effective hand hygiene has worked well.

In order to ensure future sustainability, the practice of students, and other health professionals should

also be considered. Therefore, pre-service training and training of all staff members is mandatory for the

successful scale up of the project. Regular audits will also need to be continued.


doi: 10.11124/jbisrir-2013-1378 Page 331

Conclusion

This project provides an example of the power of evidence based audit and feedback as a tool for

implementing best practice in the health care setting. Even in a context of low resources, this strategy for

promoting best practice is effective. The use of social influence theory and leadership theory in

implementing effective hand hygiene has been effective in helping to improve compliance rates. The

project also showed that role modeling, poster reminders, best practice procedure description, as well as

education could be used to increase adherence to effective hand hygiene. Involving key stakeholders with

the project is vital for success in changing health care practice. To sustain the gains achieved, continued

training and further audit and feedback cycles will be necessary. Moreover, frequent facility assessments

are important in order to fill the gaps in the enabling environment.

Conflict of interest

There are no conflicting interests to declare.

Acknowledgements

We would like to thank the JBI staff for both technical and administrative support to undertake the Clinical

Fellowship program, as well as AusAID for funding this opportunity. We would like to extend our

appreciation to the team members and staff nurses of JUSH medical OPD for devoting their time for the

project.


doi: 10.11124/jbisrir-2013-1378 Page 332

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Appendix 1: Grip matrix - Identified barriers to best practice and strategies to overcome them

Barriers Strategies Outcomes

Knowledge and skill gaps regarding hand hygiene products and the five moments of hand hygiene

1. using JBI evidence summary

2. Demonstrations, role modeling and Reminders

3. Making hand hygiene a discussion point every morning

There is a significant change in compliance to hand hygiene

Poor attitude towards hand hygiene

1. Demonstration

2. Norm setting

3. Establishing Nurses’ champion for effective HH

4. Providing JBI evidence summary

The attitude change can be implied from the increment in compliance

Negligence and forgetfulness

1. Posting HH procedure

2. Setting group norms

3. Making a discussion point every morning

The attitude change can be implied from the increment in compliance

The perception/experience of skin irritation

1. Delivery of HH cream to service delivery points

2. Demonstration/role model

The change in perception can be implied from the increment in compliance

Work load/time constraint 1. Engaging medical, health officer and nursing graduates

2. Assigning the Nurse staffs fairly based on work load in each unit

Students shared the load

Shortage of HH products (alcohol hand rubs, lotion and cream/glycerin)

Timely purchasing and delivering them to the point of care

Hand hygiene products were availed

Inconsistent water supply Ensuring continuous water supply Water supply was made continuous throughout the project

The changing shifts of nurses posed difficulty in data collection and onsite demonstration

Working during after hours Data collectors and the team contacted the nurses during their respective shifts.


doi: 10.11124/jbisrir-2013-1378 Page 335

Appendix 2: Posters

1 2 3 4

5

6

78910

11

12

1 2 3 4

5

6

78910

11

12

Figure 3: Procedures in effective hand hygiene posted on the walls of OPD


doi: 10.11124/jbisrir-2013-1378 Page 336

Figure 4: Reminder for hand hygiene posted on the walls of OPD


doi: 10.11124/jbisrir-2013-1378 Page 337

Figure 5: Five moments of hand hygiene posted on the walls of OPD

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