PICOT Statement and Literature Search

Background

It is irrefutable that despite the implementation of measures to enhance the outcome of care in clinical settings, challenges that negatively affect this objective still exist. Incidences of nosocomial infections due to noncompliance with hand hygiene practices, for instance, have devastating implications for the health of patients. During training, nurses are informed of the importance of complying with hand hygiene protocol to minimize the incidence of nosocomial infections. They are also informed of some of the methods through which these infections can be minimized. Hand hygiene has been identified as a critical component of health care professional’s scope of practice and is applied in all patient care processes.

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All care providers are required to comply with hand hygiene practices to prevent incidences of healthcare-acquired infections. Hand hygiene needs to be performed before and after contact with the patient. The hands should also be cleaned if they get contaminated during the process of care. It has been scientifically proven that performing hand hygiene reduces the number of microorganisms on the hands of care providers thus decreasing the risk of spread to the patients. Research, however, has revealed that the number of nurses who comply with hand hygiene protocol is significantly small.

Moreover, most nurses are not aware of the most effective hand hygiene strategy. Whereas some nurses wash their hands with soap and water, others argue that they only feel that their hands are disinfected properly if they use alcohol-based agents. This paper recognizes that nurses can make a difference in nosocomial infections by washing their hands with alcoholbased disinfectants. A comprehensive literature search on hand hygiene and nosocomial infections will be carried out to identify articles with relevant information on these issues.

PICOT Statement

This paper will use a PICOT format to generate information to show how nosocomial infections can be eradicated in clinical care settings. The picot statement will be, “in critically ill patients in the ICU, does nurses’ hand washing with alcohol-based disinfectants as compared to handwashing with water alone, have the potential to reduce the incidence of nosocomial infections in one month?”

Population: Critically ill patients in the ICU

Intervention: Nurses handwashing with alcohol-based disinfectants

Comparison: Hand washing with water alone

Outcome: Decreased incidence of nosocomial infections

Time: one month

Literature Search

The purpose of the literature search is to generate information explaining why nurses need to comply with hand hygiene as well as the evidence behind the use of alcohol-based disinfectants in hand hygiene practices. In this project, the literature search was performed using electronic databases including CINAHL, PubMed, MedLine, and Ebscohost. These databases were used since they contain a large number of qualitative and quantitative research articles with information addressing various health issues. Search terms were used to ensure the articles generated addressed the issue of hand hygiene and nosocomial infections. The search terms included hand hygiene, hand washing with soap and water, hand washing with alcohol-based disinfectants, nosocomial infections, and critically ill patients. Over five hundred articles addressing various aspects of the research topic were generated. An inclusion/exclusion a criterion was used to ensure that only the relevant articles were used in the review. For instance, articles that were more than five years were excluded together with those that were written in a language other than the English language. Articles that addressed hand hygiene in other settings apart from clinical settings were also excluded. Six articles which fulfilled the inclusion criteria were selected for review. A summary of the articles generated during the search has been provided in Appendix 1.

Literature Review

Quantitative, Peer-Reviewed Research

The article by Yildrim et al. (2014) has made it clear that the incidence of all forms of candida infection has increased significantly. Incidences over the last few decades have led to Candida spp. being categorized as the fourth most common form of pathogenic microorganisms recovered from the blood of hospitalized patients in the United States. The authors pointed out that even though candida infections are largely endogenous, human to human transmissions are possible.

It has been revealed that there is a high likelihood of candida being carried on the skin of health care workers. These infections are responsible for poor health outcome, prolonged stay in the hospital and the increased cost of care (Murni, Duke, Kinney, Daley, & Soenarto, 2015). The authors also noted that outbreaks induced by Candida spp. have been reported in different health care organizations. The outbreaks were attributed to the transfer of candida from the hand of the care providers to the patients.

The fact that the hands of nurses are important for the colonization as well as the infection of hospitalized patients with candida was the main aspect that drove the researcher to conduct this study (Yildrim et al., 2014). The study was aimed at evaluating the ability of various hand disinfectants to reduce Candida spp. on the hands of nurses. The author did not provide explicit research questions for this study. However, the research questions can be deduced from the study purpose since they are related. One of the questions that might have guided the researchers, for instance, is: “What is the effectiveness of various disinfectants including alcoholbased solution, iodine, and chlorhexidine in reducing the Candida spp. load on the hands of healthcare personnel?”

Method of study

The study described by Yildrim et al. (2014) is a quantitative study. The researchers carried out a controlled study with eighty hospital personnel at Duzce University School of Medicine Hospital for one month. The participants, who included medical students, nurses, doctors, and other healthcare staffers, were observed by an infection control nurse to ensure strict compliance with hand hygiene. All potential participants with bruises and other skin conditions were excluded from the study. The quantitative approach was appropriate for the research question since it would provide statistical findings on the bacterial load on the hands of the personnel.

The participants were allocated to four groups. The intervention arm of the study, which involved the use of disinfectants had three groups whereas the control group, which involved hand washing with water and plain soap, had only one group (Yildrim et al., 2014). The researchers did not identify a specific perspective from which this study was conducted. They have, however, cited a range of qualitative and quantitative resources containing information relevant to the use of disinfectants in preventing infections. The authors used studies that were published over 20 years ago. In most cases, the use of sources older than five years is allowed if they are quantitative studies.

Unfortunately, the author did not identify the strengths and weaknesses of the available studies. Moreover, a separate literature review section was not included in this article. The authors instead integrated the literature review into the introduction section. The information contained in the review is, however, relevant, adequate and applicable to the creation of a logical conclusion.

Results of study

The study findings were categorized according to the ability of the hand disinfectants to reduce to eliminate candida spp. from the hands of the participants. The study revealed that the participants in the intervention group had significantly lower levels of candida load as compared to their counterparts in the control group. However, varying results in the intervention group were generated according to the type of disinfectant used. The rate of candida hand carriage was

10.5% (the lowest) in the participants who used 4% chlorhexidine gluconate and highest in the control group where participants used water and plain soap to wash their hands (Yildrim et al., 2014). Candida hand carriage was significantly higher among the participants who used 7.5% povidone-iodine, and alcohol-based disinfectants (Yildrim et al., 2014). The differences were minor among the participants who used hand disinfectants.

Application to practice

The findings of this study can be applied to nursing practice with remarkable outcomes. The findings concur with Li, Xu, and Zhao (2014) that the use of hand disinfectants eliminates a larger bacterial load from the hands of the healthcare personnel as compared to water and plain soap. Therefore, the development and implementation of organizational policies promoting the use of hand disinfectants would reduce the rate of nosocomial infections. In concurrence with Murni et al. (2015), these findings contribute to the nursing knowledge by confirming that the hands of health care staffers harbor a huge load of potentially pathogenic microorganisms which can only be eradicated through the use of appropriate hand hygiene practices. The knowledge generated from this study can have a potential impact on practice, education, administration and other areas of nursing. For instance, nurses can use the information provided in the current study to determine the most effective strategies for reducing a load of infectious agents on their hands. Moreover, nurses can be trained on some of the most effective ways through which healthcareacquired infections can be prevented.

Ethical consideration

The study was conducted according to the established research standards and protocol. The participants were provided with information concerning all aspects of the study including its relevance to nursing practice. The participants were required to give a written informed consent to take part in the study. The study protocol was carried out per the Declaration of Helsinki and Good Clinical Practice Guidelines. The approval for the research study was done by the Ethics Committee of Duzce University School of Medicine (Yildrim et al., 2014).

Conclusion

Hand hygiene plays an invaluable role in the prevention of healthcare-acquired infections since the hands of nurses are important for the colonization as well as the infection of hospitalized patients. Nurses should employ appropriate prevention measures to ensure the negative consequences associated with nosocomial infections such as outbreaks, poor health outcome, prolonged stay in the hospital and increased cost of care. The use of 4% chlorhexidine gluconate has been identified as the most effective way of clearing pathogenic microorganisms including Candida spp. from the hand of healthcare personnel. Other disinfectants that can be applied for this purpose are alcohol-based hand rubs and 7.5% povidone-iodine.

Qualitative, Peer-Reviewed Research

The article by McLaws, Farahangiz, Palenik, and Askarian (2015) has made it clear that hand hygiene is one of the most important strategies through which care providers can address the issue of nosocomial infections. Hand hygiene prevents the spread of pathogenic microorganisms from the hands of the caregivers to the patients. The authors have pointed out that hospital-acquired infections affect more than a million people globally each year. These infections lead to increased cost of care making prevention a top priority. The common hand hygiene practices used in clinical care settings is hand washing with soap and water as well as the use of alcohol hand rubs (Murni et al., 2015). Unfortunately, as pointed out in the article, the rate of compliance with hand hygiene practices is significantly low. The rate of compliance has traditionally remained at between 40 and 45% (Salama, Jamala, AlMousa, Al-AbdulGhani, & Rotimi, 2013). These rates have been shown to improve when the facility implements strategic measures to sensitize the caregivers on health benefits. Various factors including knowledge, beliefs, and attitude are believed to affect the compliance of caregivers with hand hygiene policy. The study by McLaws et al. (2015) was aimed at evaluating various aspects of hand hygiene from the perspective of the health care staffers. This evaluation was believed to have the capacity to determine how knowledge, beliefs, and attitude influence the rate of compliance with hand hygiene among health caregivers. The researchers did not indicate a specific research question for this study. However, the possible question that guided this study was: ‘What are the main individual and organizational factors that influence the rate of compliance with hand hygiene among caregivers?”

Method of Study

The article describes a qualitative study conducted in two healthcare facilities in Iran, a public, and a private hospital. The hospitals were selected for this study since they had not implemented an infection control or hand hygiene policy. The researchers used a purposive sampling method to get a representative sample from the health care staffers. Potential participants were encouraged to take part by asking them a set of questions related to the study. A total of 80 healthcare workers including ICU nurses, surgical ward nurse medical students, physicians and support staff. The participants were allocated to eight focus group discussions (McLaws et al., 2015). Data collection was done through one-on-one interviews on eight discussion groups. The focus group discussions lasted for approximately one hour.

The authors did not identify the specific perspective from which the research was developed. The author used both qualitative and quantitative studies as sources of information to back up the study. Materials from international health organizations such as the WHO have also been included in the article. Most of the references are current. However, some of the materials are more than ten years old. The authors did not include an assessment of the available studies detailing their strengths and weaknesses. However, the literature review is sufficient to facilitate the development of a logical argument.

Results of Study

The researchers were able to generate relevant information to answer the research question. This information was categorized into three major themes: the relationship between environmental factors, personal factors and the impact of the health system with hand hygiene compliance. The report by McLaws et al. (2015) that the hands of health care workers are a prime vector for the transmission of pathogenic microorganisms in clinical care settings was affirmed by Chatfield, Nolan, Crawford, and Hallam (2016). They also stressed the importance of complying with hand hygiene practices besides agreeing on its role in the prevention of infection transmission. The researchers also noted that some health care staffers had limited understanding of the essence of hand hygiene. McLaws et al. (2015) reported that some nurses were asking whether it was necessary to wash their hands before attending to each patient in their units. It was also noted that the work environment played a major role in enhancing compliance with and hygiene practices. For instance, the availability of resources was identified as a major booster to compliance. The participants also noted the health system had a significant impact on the level of compliance. Some participants indicated that inadequate support of health care workers by the national health system demoralizes the care providers and increases the resistance towards certain health policies (McLaws et al., 2015).

Application to practice

The findings of this study are significant to nursing practice. These findings have highlighted some of the critical factors that are likely to influence the caregivers’ compliance with hand hygiene and other infection control measures. The findings can thus be used in the development of policies that can potentially address the issues that lead to noncompliance. Nurses can collaborate with other stakeholders to transform the working environment to increase compliance. These findings have contributed significant information aimed at enhancing nursing knowledge and research. Nurses can rely on the findings of this study to develop infection control policies at the organizational level. Furthermore, the findings have the potential to impact nursing practice, knowledge, education and administration as well as other areas of nursing. Educational and training programs can be developed based on these findings to increase awareness and sensitize health care staffers of the importance of compliance with hand hygiene.

Ethical Considerations

The researchers noted that ethical approval for this study was not required. The participants were not subjected to unethical and potentially harmful treatment procedures. The researchers did not declare any possible conflict of interest. The study was based on data collected through focus group interviews. The participants were, however, required to provide an oral consent before being included in the study. Even though the facilitator began by asking a set of questions aimed at encouraging potential participants to take part in the study (McLaws et al., 2015), the participants were not coerced. The participants were not provided with monetary incentives.

The link between the PICOT statement, the research articles, and the nursing practice problem

The PICOT statement, the research articles, and the nursing practice problem are connected since they address the same issue. The problem being addressed in this paper is the lack of compliance with hand hygiene due to a lack of understanding of the most effective hand hygiene practice. It has been revealed that the level of adherence to hand hygiene practice is wanting. Noncompliance predisposes a large number of patients to the risk of nosocomial infections. A picot format was used to generate information to help determine whether the use of alcoholbased agents have better disinfection capacity than hand washing. The picot statement summarizes all the aspects identified in the practice problem statement and the literature review. The literature review provides information obtained from qualitative and quantitative articles addressing hand washing and hand disinfection.

Proposed Evidence-Based Practice Change

This paper proposes the use of alcohol-based disinfectants in hand hygiene as a practical way of reducing nosocomial infections. Alcohol-based disinfectants are more effective in eradicating transient flora on the hands of nurses and other healthcare staffers than water alone (Yildirim et al. (2014). Studies have generated results indicating that the antibacterial efficacy of hygienic hand disinfection is far much better than hand washing. Hand disinfection should, therefore, be performed before and after the nurse comes into contact with the patient. Hand washing is only advisable when then hands are soiled during the process of care delivery.

Conclusion

In critically ill patients in the ICU, nurses’ hand washing with alcohol-based disinfectants as compared to handwashing with water alone, has the potential to reduce the incidence of nosocomial infections in one month. Alcohol-based disinfectants are more effective in eradicating transient flora on the hands of nurses and other healthcare staffers than water alone. A higher dose of disinfectant eliminates a significantly higher number of transient microorganisms thus leading to less colony forming units thus a decreased risk of infections. Education on hand hygiene increases compliance among health care staffers and subsequently reduces the rate of nosocomial infections. Environmental and personal factors together with the impact of the health system have a significant influence on compliance with hand hygiene. It is irrefutable that the hands of health care workers are a prime vector for the transmission of pathogenic microorganisms in clinical care settings. Nurses and other care providers have a responsibility to comply with hand hygiene practices to curb potential incidences of health acquired infections.

References

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.

Li, X., Xu, C., & Zhao, S. (2014). Experimental study on disinfection effect of different dose of rapid hand disinfectant. International Journal of Nursing Sciences, 1(2), 212-214.

https://doi.org/10.1016/j.ijnss.2014.05.006

McLaws, M., Farahangiz, S., Palenik, C. J., & Askarian, M. (2015). Iranian healthcare workers’ perspective on hand hygiene: A qualitative study. Journal of Infection and Public Health, 8(1), 72-79. https://doi.org/10.1016/j.jiph.2014.05.004 doi:10.1136/archdischild-2014-307297 https://doi.org/10.1016/j.jiph.2012.09.014

Murni, I. K., Duke, T., Kinney, S., Daley, A. J., & Soenarto, Y. (2015). Reducing hospitalacquired infections and improving the rational use of antibiotics in a developing country: an effectiveness study. Archives of Disease in Childhood, 100(5), 454-459.

Salama, M. F., Jamala, W. Y., AlMousa, H., Al-AbdulGhani, K. A., & Rotimi, V. O. (2013). The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. Journal of Infection and Public Health, 6(1), 27-34.

Yildirim, M., Sahin, I., Oksuz, S., Sencan, I., Kucukbayrak, A., Cakir, S., & Ozaydin, C. (2014). Hand carriage of Candida occurs at lesser rates in hospital personnel who use antimicrobial hand disinfectant. Scandinavian Journal of Infectious Diseases, 46(9), 633636. doi:10.3109/00365548.2014.922694

Appendices

Appendix 1: Summary of the Articles https://doi.org/10.1016/j.ijnss.2014.05.006 https://doi.org/10.1016/j.jiph.2012.09.014 doi:10.1136/archdischild-2014-307297

Li, X., Xu, C., & Zhao, S. (2014). Experimental study on disinfection effect of different dose of rapid hand disinfectant. International Journal of Nursing Sciences, 1(2), 212-214.

The study by Li, Xu, and Zhao (2014) describe a quantitative study whereby then researchers employed an Experimental study design to determine the impact of using a different dose of rapid hand disinfectant on disinfection. The researchers used a sample of 74 nurses who were randomly assigned to two groups. Hand swabs were obtained before and after infection and cultured to determine the number of colony-forming units. It was discovered that a higher dose of disinfectant eliminates a significantly higher number of transient microorganisms thus leading to less colony forming units.

Salama, M. F., Jamala, W. Y., AlMousa, H., Al-AbdulGhani, K. A. & Rotimi, V. O. (2013). The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. Journal of Infection and Public Health, 6(1), 27-34.

Salama et al. (2013) also conducted a quantitative study using interventional study design to ascertain the effect of compliance with hand hygiene on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital. A direct observation method was used to measure compliance. The researchers noted that education on hand hygiene increased compliance among health care staffers and subsequently reduced the rate of nosocomial infections.

Murni, I. K., Duke, T., Kinney, S., Daley, A. J., & Soenarto, Y. (2015). Reducing hospitalacquired infections and improving the rational use of antibiotics in a developing country: an effectiveness study. Archives of Disease in Childhood, 100(5), 454-459.

The article by Murni et al. (2015), describes a quantitative study whereby the researchers wanted to show how hospital-acquired infections and the overuse of antibiotics can be alleviated through a multifaceted intervention comprising of hand hygiene campaign, elementary infection control practices, and antibiotic steward programs. Data were collected before and after the intervention. The study revealed that hospital-acquired infections reduced significantly following the hand hygiene campaign. Furthermore, the infection control resulted in a rational use of antibiotics.

Yildirim, M., Sahin, I., Oksuz, S., Sencan, I., Kucukbayrak, A., Cakir, S., & Ozaydin, C. (2014). Hand carriage of Candida occurs at lesser rates in hospital personnel who use antimicrobial hand disinfectant. Scandinavian Journal of Infectious Diseases, 46(9), 633-636. doi:10.3109/00365548.2014.922694

Yildirim et al. (2014) describe a quantitative study whereby the researchers conducted a controlled study using 80 hospital staffers to determine the rate of candida infections in hospital personnel upon the use of antimicrobial hand disinfectants. The participants were divided into four groups: group 1 used alcohol-based hand rubs, group 2 used 4% chlorhexidine gluconate, group 23 used 7.5% iodine and group 4 washed their hands with soap and water. The researcher found out that hand washing with antimicrobial agents is more effective in reducing the rate of candida infection as compared to hand washing with soap and water.