WSU REPOSITORY MSN/DNP Project Title by Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT Date Student Name, Credentials (electronic signature) Date MSN Project Faculty (electronic signature) Date 4/26/24 (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Hand Hygiene Compliance Natasha Begonia, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purpose/Aims: This project aimed to implement formal education on proper hand hygiene (HH) practices, reinforced with tactile and visual reminders, to improve HH compliance among nursing staff in a rehabilitation unit. Rationale/Background: Although HH is vital in reducing hospital-acquired infections (HAIs), formal HH education is lacking in many clinical settings. This project addresses the need for improved HH compliance through evidence-based interventions such as education, reinforcement, and visual reminders. Methods: This project is based on Stetler’s evidence-based practice model and includes preparation, validation, comparative evaluation, application, and evaluation phases. The implementation plan provides education sessions, tactile reinforcement with Glo Germ and UV light, laminated signage, ABHS distribution, and reinforcement pins. The interventions were analyzed through pre- and post-intervention surveys and quizzes. Results: Implementation of the HH intervention revealed significant improvements in compliance rates and identified three major themes: 1) early error correction of HH practices, 2) increased staff confidence in HH techniques, and 3) enhanced team performance in maintaining HH standards. Conclusions: By integrating formal education, tactile reinforcement, and visual reminders, this project successfully improved HH compliance among nursing staff. Keywords: Hand hygiene, compliance, healthcare-associated infections, education, reinforcement, visual reminders, interdisciplinary team, tactile reinforcement, evidence-based practice. 3 Hand Hygiene Compliance Humans have between ten thousand and ten million bacteria on their hands (University of Louisville, 2020), and practicing good hygiene habits will aid the immune system in combating illnesses. Mayo Clinic (2021) also suggests that healthcare providers wear gloves, apply hand sanitizer, and wash hands with soap and water to maintain good hand hygiene (HH). Understanding how and when to perform these everyday tasks is crucial for nurses' and patients' health. The World Health Organization (WHO) (2020) argues that organizations can enhance HH compliance with nursing staff with access to alcohol-based hand sanitizers (ABHS), education and training, compliance monitoring and feedback, and visual cues to perform HH. Toney-Butler et al., (2023) further note that hospitals may decrease infectious disease transmission and hospital-acquired infection (HAI) rates by implementing the above strategies. Statement of Problem Despite studies demonstrating the significance of HH in lowering HAIs and staff exposure to infectious diseases, formal HH education remains scarce in many clinical settings (Sebastian et al., 2021). The Centers for Disease Prevention and Control (CDC) (2022) also cites regular HH practice as a possible method of halving diarrheal disease deaths, reducing respiratory infections by sixteen to twenty-one percent, and preventing one million deaths yearly. Altin & Eren Gok (2022) discovered that HH compliance may be enhanced by applied interactive education in addition to “theoretical instruction transfer” (Altin & Eren Gok, 2022, p. 379). They also found that if HH visual reminders were placed throughout the facility and nurses got personalized feedback, noncompliance would substantially decrease (Altin & Eren Gok, 2022). 4 A seven-hundred thirty-one-bed hospital in California does not provide formal education on proper HH. Baseline data from the hospital indicated that all departments practice HH at less than seventy-five percent. The Respiratory Rehabilitation Unit (RRU) compliance rate was reported to be sixty-five percent, above the worldwide average of forty to sixty percent, but still significantly low (World Health Organization, 2023). This is alarming as most patients in RRU need ventilator support, tracheostomy care, intermittent bladder catheterization, daily bowel training, and twenty-four-hour respiratory management. Significance of the Project The primary purpose of this project is to implement change by introducing formal education on proper hand hygiene with physical reinforcements and reminder systems. This project can positively impact hospitals because an increase in HH compliance rate of seventyfive percent and above can help reduce the spread of bacteria and viruses (Altin & Eren Gok, 2022). According to the CDC, one in thirty-one patients admitted to the hospital contract a HAI, increasing the excessive cost of healthcare in the United States (Vaughan-Malloy et al., 2023). HH is the most vital element in preventing HAIs and would impact the workplace by decreasing the length of hospital stays and keeping staff safe from infectious diseases (Toney-Butler et al., 2023). This project focuses on decreasing the risk of HAIs through integration of formalized HH teaching with hands-on reinforcement at unit-specific skills days and new hire orientations. Hospitals could benefit from this initiative by improving HH compliance rates, which decreases the risk of HAIs and mitigates the additional healthcare costs associated with them (Altin & Eren Gok, 2022). 5 Literature Review HH issues persist among healthcare workers despite extensive training. Many studies show that healthcare workers receive comprehensive instruction and training in HH, including correct techniques and suggested practices. With this understanding, healthcare workers still have low compliance rates (Paul et al., 2019). According to research, the disparity is caused by insufficient resources and feedback (Winship & McClunie-Trust, 2016). This literature review will provide evidence for interventions shown to enhance provider compliance with HH guidelines. Framework The framework for this project is Stetler’s model. Melynk & Fineout-Overholt (2019) define the framework as having five phases: preparation, validation, comparative evaluation/decision-making, application, and evaluation. This framework’s structure emphasizes evidence-based decision-making, promoting change, adaptability, cooperation, and critical thinking (Dusin et al., 2023). In the first phase, HH education, ensuring that nurses have access to ABHS, ongoing monitoring, visual reminders, and feedback on compliance have been identified as ways to improve HH (World Health Organization, 2020). The validation phase confirmed the criticality of HH for HAI protection and employee safety (Marin, 2021). The WHO (2020) suggests performing HH five times during patient care. These five times are listed by the WHO (2020) as prior to performing clean and aseptic procedures, after bodily fluid contact, following patient contact, and following interaction with the patient’s environment. The comparative phase focuses on formal education and physical reinforcement of HH. To date, there are no ABHS at the nurses’ station and more reminders about proper HH should 6 be posted in RRU. In the fourth phase, a PowerPoint presentation and brochure about HH will be given to the bedside nurses. A QR code containing a link to a quiz and questionnaire about nurses’ current HH habits will be printed on the handout during this presentation. This quiz and questionnaire will assess nurses’ knowledge of HH practices and let them describe barriers to HH practices and suggestions for improving compliance. Huybrechts et al., (2021) state the fourth phase will decide how to use the data in real-life scenarios. This would include removing barriers that staff members think are hindering compliance and putting HH signage where nurses feel it would encourage them to perform HH. Stetler’s model ends with an evaluation. The outcomes of the evidence-based practice change and its effectiveness will be assessed via a QR code survey to see if the barriers they previously encountered have been lowered. Then, a final observational audit will be performed to reevaluate conformity (Huybrechts et al., 2021). Limitations and Strengths Melynk & Fineout-Overholt (2019) describe this framework as being a “practitionerorientation model (p. 384) since it stresses the application of the practitioner’s thinking and findings. It also fosters progress in other various healthcare settings. Dusin et al., (2023) identified three limitations of this model: The first is that patient preferences are not considered and second, the user requires a particular level of experience to evaluate evidence findings. Third, the model follows a specific timeline. This timeline could be problematic since some research approaches require frequent revisions because of feedback (Dusin et al., 2023). 7 Literature Analysis A literature review revealed three topics of HH barriers: first, a lack of formal education on infection prevention and control, and HH's relation to HAIs. Second, the need for expanding access to ABHS to support consistent HH, and third, the use of reminders, in the form of signage, to prompt nurses to perform HH. Search Strategies Recent evidence was identified through literature searches conducted through Google Scholar, Weber State University’s OneSearch, and JBI. For the purpose of this literature review, only articles published between two thousand sixteen and two thousand twenty-two were included. Use of the search terms included alcohol-based hand sanitizer, WHO’s five steps for HH strategy, HH compliance, HH education, HH methods, HH for nursing, HH guidelines, HH interventions, and HH monitoring technology. Education An integrative review conducted by Winship & McClunie-Trust (2016), concluded that teaching nurses the WHO’s Five Moments for HH and emphasizing infection prevention knowledge increase the significance of performing proper HH. According to a quantitative study by Muller et al., (2020), educating healthcare providers on HH makes them more aware of the role it plays in preventing disease transmission. The assessment of proper HH by Muller et al., (2020) was significantly greater than the baseline (+6.0, p <0.001) when compared to posteducation follow-up. In addition, Marin (2021) performed a systematic review of HH compliance and discovered baseline HH compliance was forty-one percent and post-intervention education 8 HH compliance rose to sixty-six percent. These studies illustrate how providing healthcare providers with information and training supports their ability to prioritize HH practices. Accessibility Since ABHS offers a quicker alternative to conventional handwashing, access to ABHS should be provided. Marin (2020) aimed to provide the best evidence available for the benefit of ABHS for HH in preventing infection transmission in the healthcare setting and how improved accessibility can boost staff compliance. This analysis indicates that having ABHS helps adopt a “point-of-care” mentality towards HH wherein medical providers could quickly sanitize their hands before and after patient contact. ABHS proximity to patient care sites acts as a reiterative reminder and promotes HH. ABHS is also helpful when water and soap are unavailable or scarce (Marin, 2020). In a similar study, Muller et al., (2021) combined qualitative and quantitative approaches to explore the impact of the WHO’s strategy in Guinea. The long-term benefits of the plan and HH compliance with ABHS were the guiding principles of this hybrid approach. Compliance increased “after patient contact” compared to “before patient contact” when accessibility to ABHS increased. The compliance rate increased from twenty-three percent to seventy-one percent. Additionally, it is essential to note that although ABHS is practical and convenient, hand washing with soap and water continues to be advised (Porritt, 2020). Signage Reminder System Hand hygiene signage is created to function as a reminder to healthcare providers concerning HH and its significance. Marin’s (2021) mixed-method evaluation found that reminders for providers enhance compliance with HH guidelines which is fundamental for disease prevention and patient safety. Additionally, a field experiment evaluating the 9 effectiveness of ABHS signage identified that ABHS that included signage saw a thirty-five percent increase in ABHS usage in comparison to ABHS dispensers without (Capps et al., 2022). Summary of Literature Review A systematic review of the literature findings concludes that HH compliance amongst healthcare providers can be enhanced through HH signs, ABHS accessibility, and education (Marin, 2021). HH is vital to avoiding infectious disease transmission in hospitals (Toney-Butler et al., 2023). Hospitals should provide their staff members with all the knowledge and tools required to minimize HAIs and assure the security and comfort of patients, visitors, and staff. Project Plan and Implementation This section proposes a comprehensive project plan and implementation strategy to improve HH compliance among nurses. The initial week will involve educating nurses on RRU through a dynamic approach, including a PowerPoint presentation, brochure, and a QR codebased assessment to gather insights into their current practices and potential barriers. Then a tactile reinforcement using Glo-germ and UV (ultraviolet) light will visually illustrate the importance of thorough HH. The five-week implementation plan includes incorporating HH champions, strategic signage placement, distribution of ABHS, administration of reminder pins, along with a final observation to gauge the effectiveness of the implemented interventions. This multifaced approach aims not only to educate but also to address real-world challenges faced by nurses, resulting in an ongoing effort to improve HH adherence. Further details on each phase will be elaborated in the plan and implementation process. Plan and Implementation Process In the first week of implementation, the project will begin with an educational session targeting all nurses on RRU. The session will incorporate a PowerPoint presentation along with 10 an informative brochure on HH. The brochure will include a QR-code leading to a quiz and questionnaire where nurses can test their current knowledge of proper techniques and express any barriers they face in maintaining compliance. This information will be gathered using the SWOT method, to fully understand the unit’s strengths, weaknesses, opportunities, and threats associated with HH. Following the education phase, a physical reinforcement demonstration will be performed using Glo Germ, a fluorescent gel stimulating germs, and UV light. Nurses will apply the gel to their hands like lotion and then wash their hands as normal. With the use of a UV light, the remaining “germs” will become visible, providing a tangible demonstration of the efficacy of proper HH practices. This hands-on activity aims to enhance awareness among nursing staff (Aouthmany et al., 2022). In the second week, HH champions within RRU will be identified and briefed on the current compliance rates. These champions will play a role in promoting and sustaining proper HH practices among their colleagues. Simultaneously, laminated signage with a reminder to perform HH will be placed outside patient rooms, near sink areas, and at the nurses’ station (World Health Organization, 2020). The signage will be simple, ensuring easy readability and comprehension. The third week will involve the placement of ABHS at the nurses’ stations and other areas where access to soap and water is limited. This step aligns with the global guidelines from the WHO, ensuring that the necessary resources are readily available to support consistent HH practices (World Health Organization, 2020). Additionally, the team will review the questionnaire responses from nurses and consider additional interventions based on their suggestions to further enhance compliance. 11 As the project progresses into the fourth week, reinforcement will be implemented by distributing pins that nurses can wear on their badge reels or scrubs. The pins and verbal reminders will emphasize the importance of HH compliance and instill a sense of responsibility among nursing staff (World Health Organization, 2020). The fifth and final week will involve a visual observation of nurses during both morning and evening shifts for one day. This phase will evaluate the impact of the implemented interventions on HH compliance. To gauge the impact of this project, nurses will be provided with a post-survey featuring a QR code. All data collected will be utilized by nurse educators to develop a future HH compliance program for all units. Interdisciplinary Team The success of this HH compliance project is a joint effort among nurses, managers, and educators. A collaborative culture will be created when HH champions act as advocates, nurse educators help introduce a future educational session, rehabilitation floor nurses participate and support HH compliance efforts, and managers sustain all team efforts (James, 2021). This coordinated effort will ultimately contribute to a safer patient care environment, enhancing quality of care and reducing the risk of HAIs. Hand Hygiene Champions. The HH nurse champions will act as the primary advocate and point of contact for HH compliance within the unit. These champions will support this project by adding improvement suggestions, promoting adherence to HH protocols among floor nurses and reminding them of the importance of compliance. These advocates will also serve as liaisons between nursing staff and management to help manage communication and address issues or challenges with compliance. 12 Nurse Educators. Nurse educators will assist in the educational component of this HH initiative. They will help develop annual training sessions at unit skills days to provide nursing staff with knowledge and skills to maintain proper HH practices. The educators experience will be beneficial in incorporating the HH educational sessions into standardized orientation programs for new employees and continuing training modules for existing staff to ensure that all members of the healthcare team know how to maintain HH. Managers. Managers will provide essential support to ensure the HH program is implemented. The managers approve the HH education implementation and will ensure nurses have the proper resources to perform HH. This will include providing ABHS outside doors and at the nurse’s station. Managers will also monitor compliance rates and provide feedback to nursing staff monthly to reinforce the need for good HH habits. Managerial leadership will be critical in resolving challenges throughout the implementation process to ensure the initiative moves forward smoothly and is sustainable. Rehabilitation Floor Nurses. Rehabilitation floor nurses, who are directly involved with patient care, will be key in implementing the HH initiative daily. The nurses will participate in educational sessions and interact with HH champions to assess how well strategies are being implemented and make suggestions for improvement where needed. The floor nurses will also emphasize HH during patient care activities, as these are essential in preventing HAIs and maintaining patient safety. The clinician’s commitment to maintaining HH standards will be crucial to the success of this project and to patient safety. Description and Development of Project Deliverables The project will include a multifaceted HH compliance program for nursing staff, including education, reinforcement, and visual reminders. There will be five deliverables utilized 13 for this project and they will be presented in the order listed in the next section. Each deliverable plays a crucial role in reinforcing the significance of HH compliance and encouraging nurses to prioritize patient safety through adherence to proper HH practices. Hand Hygiene and Compliance PowerPoint Presentation The first deliverable will be a PowerPoint will be presented to staff to explain the need for HH and formal education to ensure compliance (See Appendix A). Providing education to healthcare providers about HH increases their awareness of its role in preventing the transmission of diseases (Winship & McClunie-Trust, 2016). This presentation will use WHO and CDC research to emphasize the importance of HH in preventing HAIs, tips for when to change gloves and how to perform HH with ABHS. Brochure The second deliverable will be a brochure (See Appendix B) to educate nurses on crucial facts and guidelines about HH, including when and how to perform HH with soap and water according to the WHO’s five moments for HH (Centers for Disease Control and Prevention, 2022; Minnesota Department of Health, 2022; World Health Organization, 2020). A QR code will be included in the brochure that links to a quiz and questionnaire designed to assess nurses’ knowledge and understanding of HH practices and common barriers they face. Quiz and Questionnaire The third deliverable will be a quiz and questionnaire (See Appendix C). The quiz is prefaced with a video on HH for Healthcare Workers provided by the CDC (2017), followed by twelve questions. Each question will assess nurses’ knowledge based on the PowerPoint presentation and brochure. The quiz and questionnaire will include multiple choice, true and false, and select all that apply questions. The last three questions will ask nurses what barriers 14 they face at work that prevent them from performing HH, what they feel will help increase HH compliance, and where signage should be placed as a reminder to perform HH. Laminated Signage The fourth deliverable will be a blue laminated sign (See Appendix D) that will be placed near doors and ABHS stations, to serve as visual reminders for nurses to perform HH. Marin (2021) notes that utilizing signage as a reminder for providers to practice HH is essential for improving compliance rates. Hand Hygiene Survey The fifth deliverable will be an additional QR code linked to a HH survey (See Appendix E). The survey will ask for additional feedback, questions, concerns, and help determine if the deliverables were useful. Timeline The project timeline will be seven weeks to implement and evaluate the success of this project (See Appendix F). The HH initiative will start with a preparation phase, which will include a PowerPoint presentation and brochure with QR code quiz and questionnaire. The next phase will be the rollout of an educational campaign using a presentation and distribution of brochures. Hands-on reinforcement activities using Glo Germ, and UV light will further emphasize the importance of HH. Throughout the following phases, monitoring of compliance and addressing barriers identified through surveys will be prioritized. Finally, in the evaluation phase, a HH survey will be conducted to assess the impact of the interventions and gather feedback for improvements. According to the evaluation results, a final report with outcomes and recommendations for maintaining HH compliance among nursing staff will be prepared. 15 Project Evaluation The evaluation of this project will take place during the implementation process and will focus on the immediate impact of each intervention on HH compliance. The MSN student will gather immediate feedback from nurses through interactive discussion and the QR-code based quiz and questionnaire in the brochure during the week of educational sessions. This formative feedback will help to identify barriers and misconceptions that must be addressed. Nurses will also be visually monitored for their reactions during the Glo Germ and UV light demonstration to assess the effectiveness of the hands-on reinforcement activity (Aouthmany et al., 2022). Additionally, laminated signage and reminder pin distribution over the coming weeks will be evaluated for visibility and effectiveness in reminding nurses to practice HH (Altin & Eren Gok, 2022). At the projects end, an observational audit will be performed on morning and evening shifts to evaluate the interventions’ overall impact on nursing staff. The observational audit will evaluate HH compliance rates among nursing staff compared to baseline data collected prior to project implementation. Furthermore, an additional QR code post-survey will be administered to all nurses to obtain their views on the implemented interventions and their perceived HH compliance. This survey will also ask if the projected deliverables were helpful and if there are any improvement suggestions. Summative data from the observational audit and post-survey will be analyzed to assess the project’s success in meeting HH compliance among nursing staff. Any insights gained from the evaluation process will aid in improving future HH compliance efforts to create a safer patient care environment and reduce the risk of HAIs. 16 Ethical Considerations This project aims to maintain the respect and welfare of all involved. The overarching goal of increasing HH awareness among nursing staff to benefit to patient safety and health is evidence of the project’s social responsibility. By lowering the risk of HAIs, the project aligns with ethical principles, encouraging others to perform actions that benefit others. This project promotes nondiscriminatory behavior through education and reinforcement interventions to all nursing staff, regardless of background and demographics. It supports diversity by recognizing individual needs and barriers and working to develop interventions that meet the needs of a diverse workforce. Maintaining the project’s integrity will be accomplished through open communication of project objectives, methods, and transparency in disseminating results. Data from the surveys and observations will be anonymized to protect participants from privacy concerns. It will also implement confidentiality measures to keep individuals’ personal information private. People who do not want to participate in the project are going to be acknowledged, and their decision will be respected (Rashid, 2022). Discussion This project addresses the challenge of low HH compliance among nurses and uses evidence-based resources to integrate education, reinforcement, and visual reminders to instill a culture of HH adherence within the rehabilitation unit. Altin & Eren Gok (2022) emphasize the importance of interactive education and personalized feedback in enhancing HH compliance, which is integrated into the educational sessions along with tactile reinforcements. Winship & Mcclunie-Trust (2016) highlight the significance of providing comprehensive HH education to healthcare providers, which is reflected in the development of a PowerPoint, brochure, and quizzes. Additionally, Marin (2021) stresses the effectiveness of visual reminders in improving 17 HH compliance rates, a concept integrated into the placement of laminated signage and reminder pins. This project not only advances nursing practice by promoting patient safety and reducing the risk of HAIs but also offers valuable implication and recommendations for similar initiatives across Santa Clara Valley Medical Center. Evidence-Based Solutions for Dissemination After the implementation phase, the results of this project will be disseminated through multiple avenues. Initially, a comprehensive report will be generated, compiling data collected from quizzes, and observational audits. This report will be electronically shared with administrative stakeholders within the hospital for their review and deliberation on the project’s continuation. A dedicated staff meeting will also be convened specifically for stakeholders within RRU, including the nurse manager, educators, and floor nurses. Led by the project coordinator, this meeting will feature a presentation of project outcomes using PowerPoint slides, facilitating an open discussion to evaluate strengths, limitations, and recommendations for improvement, and to identify any existing gaps in the implementation process. Additionally, a poster presentation will be developed to disseminate the project findings to peers and faculty members at Weber State University. Through these dissemination efforts, the project aims to promote awareness, facilitate dialogue, and encourage further adoption of evidence-based HH practices in healthcare settings. Significance to Advance Nursing Practice By focusing on improving HH compliance among nursing staff, this project addresses an aspect of nursing practice that directly impacts patient safety and infection control. According to Muller et al., (2020), educating healthcare providers on HH significantly increases their awareness of their role in preventing disease transmission, leading to improved compliance rates. 18 By equipping nursing staff with the knowledge, skills, and resources necessary to prioritize HH practices, this project will contribute to the professional development and competency of nurses. Implications The implementation of this project has significant implications for nursing practice, patient safety, and the healthcare system as a whole. By incorporating evidence-based practice interventions and educational strategies recommended by Altin & Eren Gok (2022) and Marin (2021), this MSN project aims to address the root cause of low HH compliance rates and mitigate the risk of HAIs. Additionally, the nature of this project fosters collaboration among interdisciplinary teams, making it a collective responsibility to maintain high HH standards (James, 2021). However, potential limitations must be acknowledged and addressed to ensure the project’s success. These may include challenges related to staff buy-in, resource constraints, and the need for sustained engagement and support from hospital leadership. To address these challenges, this project will adopt strategies such as ongoing education and feedback mechanisms, as suggested by Marin (2021). The projects focus on continuous monitoring and evaluation, utilizing both quantitative and qualitative data collection methods, will enable stakeholders to assess the effectiveness of interventions and make adjustments, aligning with principles of evidence-based practice (Melnyk & Fineout-Overhold, 2019). Recommendations Some recommendations based on this implementation and outcome are presented to further enhance HH compliance. First, it is suggested to extend the projects educational initiatives to ensure sustained improvement in HH practices. This includes ongoing training sessions and skills days focused on HH, as suggested by Paul et al., (2019). Additionally, 19 incorporating interactive elements into skills days, such as role-playing scenarios or case studies, may enhance engagement and knowledge retention among staff (Altin& Eren Gok, 2022). It is also essential to prioritize providing easy access to ABHS and ensuring the availability of handwashing stations with adequate supplies. Marin (2021) and Muller et al., (2021), note the accessibility of ABHS plays a crucial role in promoting consistent HH practices. Therefore, regular audits and assessment of HH resources should be conducted to identify and address any issues promptly. Moreover, ongoing monitoring and feedback mechanisms should be established to track HH compliance rates and identify areas for improvement. This could involve the implementation of electronic monitoring systems, as recommended by Toney-Butler et al., (2023). The integration of wearable devices for real-time feedback and reminders may offer a new approach to enhancing HH practices (Sebastian et al., 2021). Conclusions Overall, the successful implementation of this project has the potential to yield benefits for nurses and patients. By promoting adherence to HH guidelines and reducing HAIs, the project supports nurses’ commitment to patient safety and quality care. Furthermore, the project outcomes may aid future initiatives aimed at improving infection control practices in healthcare settings, contributing to efforts to enhance healthcare outcomes and reduce healthcare costs associated with preventable infections (CDC, 2022; Vaughan-Malloy et al., 2023). 20 References Altin, N., & Eren Gok, S. (2022). The importance of education in the compliance of healthcare workers with hand hygiene. Journal of Ankara University Faculty of Medicine, 75(3), 379–387. https://doi.org/10.4274/atfm.galenos.2022.38981 Aouthmany, S., Mehalik, H., Bailey, M., Pei, M., Syed, S., Brickman, K., Morrison, K., & Khuder, S. (2022). Use of ultraviolet light in graduate medical education to assess confidence among residents and fellows in handwashing instruction. 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Mixed methods study evaluating the implementation of the WHO hand hygiene strategy focusing on alcoholbased handrub and training among health care workers in Faranah, Guinea. PLOS ONE, 16(8). https://doi.org/10.1371/journal.pone.0256760 Porritt, K. (2020). Hand hygiene: Indications and general principles in primary, community and healthcare settings. JBI. https://jbi.global/sites/default/files/202003/19783%20ES%20Basic%20Hand%20Hygiene-%20Health%20Professionals%20.pdf Paul, E. T., Kuszajewski, M., Davenport, A., Thompson, J. A., & Morgan, B. (2019). Sleep safe in clean hands: Improving hand hygiene compliance in the operating room through education and increased access to hand hygiene products. American Journal of Infection Control, 47(5), 504–508. https://doi.org/10.1016/j.ajic.2018.10.021 Rashid, D. (2022). Ethics in nursing research. Journal of Nursing & Care, 11(3). Sebastian, S., Madhumitha, S., George, L., Meenakshi, K., Vinson, A., & Benjamin, A. (2023). My five moments of hand hygiene: A cross sectional questionnaire based study on adherence and barriers among nurses in Central Kerala. Muller Journal of Medical Sciences and Research, 14(1), 111. https://doi.org/10.4103/mjmsr.mjmsr_30_22 Toney-Butler, T., Gasner, A., & Carver, N. (2023). Hand hygiene - StatPearls - NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK470254/ 23 Handwashing 101: UofL Health. UofL Health | Louisville Hospital and Health Care System Serving Kentucky and Indiana. (2020). https://uoflhealth.org/articles/hand-washing101/#:~:text=The%20average%20human%20hand%20houses,on%20each%20of%20your %20hands Vaughan-Malloy, A. M., Chan Yuen, J., & Sandora, T. J. (2023). Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene. American Journal of Infection Control, 51(5), 514–519. https://doi.org/10.1016/j.ajic.2023.01.013 Winship, S., & McClunie-Trust, P. (2016). Factors influencing hand hygiene compliance among nurses: an integrative review. Kai Tiaki Nursing Research, 7(1), 19+. https://link-galecom.hal.weber.edu/apps/doc/A474767015/AONE?u=ogde72764&sid=summon&xid=c6ea 87a7 World Health Organization. (2020). Hand hygiene for all initiative: Improving access and behaviour in health care facilities. World Health Organization. https://www.who.int/publications/i/item/9789240011618 World Health Organization. (2023). First-ever WHO research agenda on hand hygiene in health care to improve quality and safety of care. World Health Organization. https://www.who.int/news/item/12-05-2023-first-ever-who-research-agenda-on-handhygiene-in-health-care-to-improve-quality-and-safety-of-care 24 Appendix A Hand Hygiene Compliance PowerPoint 25 26 Appendix B Brochure 27 Appendix C Quiz and Questionnaire 28 Appendix D Laminated Signage 29 Appendix E Hand Hygiene Survey 30 Appendix F Projected Estimated Timeline