Professional Portfolio

Running Head: HANDWASHING AND CROSS INFECTIONS 0

Course Project: Hand Washing and Cross Infections

Name

Walden University

NURS 6052 - 3 Essentials of Evidenced-Based Practice

May 08, 2016

Part 1: Identifying a Researchable Problem

Hundreds of millions of patients worldwide are affected by healthcare associated infections every year (Pittet, Allegranzi & Boyce, 2009) . The infections lead to severe illnesses, long-term disabilities, prolonged hospital stays and added costs to patients, their families, and the healthcare system (Pittet et al., 2009). Hand hygiene is the primary action to reduce the number of healthcare-acquired infections; a simple action maybe, but the compliance rates among the healthcare providers is the main problem (Pittet et al. ,2009). The purpose of part one of this course project is to provide a summary on the issue of handwashing non compliance amongst healthcare workers and its relation to nosocomial infections. This paper will also generate five questions and describe how they are analyse for feasibility, as well as a PICOT question and a description of its variable. Additionally, ten keywords will be developped to help conduct the literature search.

Problem Identification

A crucial factor in selecting a problem is its significance to nursing and evidence from the study should have potential to contribute meaningfully to nursing practice ( Polit & Beck, 2012). Nurses comprise of 55% of the healthcare workforce and number more than 3 million. As such, they represent the most critical group in hand hygiene compliance as they spent the most time with the patients (McGonigle & Mastrian, 2012). Hand hygiene is a critical practice aimed at keeping the hands clean and free from pathogens or reduce the amounts before performing any medical procedure or touching a patient. Practicing hand hygiene is important in the prevention of cross infection in clinical settings. Healthcare workers need an easy to use, timely access to both skin protection and hand hygiene for good hand hygiene practice (Pittet et al., 2009)

It is well-known that better hand hygiene practices among healthcare workers play a critical role in the prevention of transmission of infectious agents (Pittet et al., 2009). The practice of hand washing is one of the most effective ways of preventing the transmission of infectious diseases. Despite the implementation of the Centers for Disease Control and Prevention guidelines for hand hygiene, the compliance among health practitioners remains low (Pittet et al., 2009).

Hand washing is a critical element of patient safety as it prevents healthcare associated infections as well as the spread of antimicrobial resistance (Bukhari et al., 2011). The promotion of hand hygiene, therefore, presents a common challenge that calls for a multimodel strategy. Healthcare worker’s adherence to hand washing guidelines is poor and calls for a behavior change (Bukhari et al., 2011). Most studies have recommended multimodal strategies that include education of healthcare workers, audit and performance feedback practices, increased supply of water and soap, reminders, use of automated sinks and the use of alcohol-based hand rub (Pfoh, Dy, & Engineer, 2013).

Hospital-acquired infections carry a far-reaching and real threat to every individual admitted to hospitals. The pathogens from the hands of the healthcare workers are readily transmitted to the patients hence, hand hygiene practices substantially reduce this chance (Bukhari et al., 2011). Evidence-based guidelines for hand hygiene in clinical practice are very clear, but the compliance remains internationally low (Bukhari et al., 2011).

Significance of the Problem of Nursing Practice

Hand hygiene is considered as the most simple and the most effective way of preventing hospital-acquired infections (Bukhari et al., 2011). Despite the milestones and achievements made in epidemiology and infection control, the hygiene message has not been consistently translated into healthcare practice, and the healthcare workers adherence to the guidelines for hand hygiene is unacceptably low (Bukhari et al., 2011). The average compliance with the hand washing guidelines varies by the patient wards, among health care workers categories and based on the working conditions, but also varies according to the different definitions used in different studies (Pittet et al., 2009).

Compliance with hand-washing recommendations is a very significant measure in the prevention of hospital-associated infections. Studies report that transmission of pathogens from the hands of healthcare workers is one of the primary sources of cross-infection in clinical settings and can be prevented by proper hand hygiene practices (Bukhari et al., 2011; Pittet et al., 2009). There are cases of very low or insufficient compliance rates in developing and developed countries with the mean baseline rates of between 5% and 89%, making an overall average of 38.7% (Bukhari et al., 2011).

Variation in hand washing behavior across healthcare workers and hospital wards suggests the need for a strategic educational program. Nosocomial infections are a significant cause of complications in the ICU; with hand-washing being the single most effective preventive measure, the compliance rates remain low (Bukhari et al., 2011). The association between handwashing non-compliance and surgical wards may also suggest that understaffing reduces the quality of patient care. Hand washing has a proven benefit in the prevention of cross-infection. Hence the compliance, especially in the surgical and ICU wards, is paramount (Royal Pharmaceutical Society, 2014).

Studies and estimations by the World Health Organization show Healthcare-associated infections affect at least 1.4million patients on the global scale at any given time (Pittet et al., 2009). In the surgical units, the burden of hospital acquired infections has significantly increased, leading to increased morbidity and mortality. In some instances, multidrug resistant pathogens are involved or are part of the infection, hence pose a challenge to effective treatment (Pittet et al., 2009). Proper hand hygiene is the simplest, single most important and the least expensive means of preventing the cross infections. The WHO (2009) guidelines on hand hygiene also propose the use of alcohol base hand rub as a means for routine hand disinfection.

Questions Related to the Identified Issue

Not all problems are amenable to research inquiries; it's important to know the significance of the problem to nursing and nursing clients, wheter the client would benfit from the evidence (Polit & Beck, 2012). Five questions related to the identify issue that leads me to my PICOT question are:

1. What are the hand hygiene practices among Healthcare workers?

Rationale

It is important to assess the types of hand hygiene practices commonly used by healthcare workers so as to determine the choices available and the recommended practices

1. What are the reasons for non-compliance with hand hygiene practice?

Rationale

It has been noted that there is moderate to low rates of compliance with standard hand hygiene practices among healthcare workers. It is, therefore, important to get to know the reasons behind the non-compliance.

1. What are the alternative hand hygiene practices?

Rationale

There exist more than one hand hygiene techniques from which healthcare workers can choose preferred as well as the simplest and most efficient method of hand hygiene practice.

1. What are the disparities in hand hygiene practices among different healthcare workers?

Rationale

The non-compliance to hand hygiene practices vary across the various cadres, ages and experience of health personnel. It is important to know the personal factors that are attributed to the variation between the different categories of health workers.

1. What can be done to improve hand hygiene practices in healthcare?

Rationale

It is also important to assess the actions that can be taken to encourage hand hygiene practices in healthcare.

The most appropriate question from the above-related questions is; Does hand washing and appropriate staff dressing among the surgical ward nurses reduce cross infection during patient management?

Description of the PICOT Question

The PICOT question is: Does hand washing and proper staff dressing among the surgical ward nurses reduce cross infection during patient management? The elements of the table are:

P- (Patient, population, or problem): nurses, hospitalized patients
I- (Intervention): hand washing and appropriate dressing
C- (Comparison with other treatment/current practice): Nurses forget to wash their hands when switching from one patient to the other

O- (Desired outcome): Reduced incidences of cross infection (Davies, 2011)

Ten Possible Keywords that Could Be Used When Conducting a Literature Search for PICOT Question and A Rationale for Your Selections

As a clinical researcher, it is important to develop strong research skills. Entering the right keywords is important in order to obtain the right resources (Polit & Beck, 2012). Ten appropriate keywords related to my research question are as followed:

1. Hand washing.

Rationale

Knowing the definition and practice of hand washing

1. Hand hygiene.

Rationale

Alternative comprehensive description of clean hands

1. Cross-infection

Rationale

Assessing the effects of poor hand hygiene and its contribution to transmission of micro-organisms from one person to the other.

1. Healthcare workers.

Rationale

The population or persons who participate in the study

1. Healthcare-acquired infections.

Rationale

The results of transmission of micro-organisms through unhygienic hands

1. Hand washing guidelines.

Rationale

What are the recommended hand washing practices for healthcare workers?

1. Hand washing nonconformance

Rationale

The percentage of conformity to the hand washing guidelines

1. Hand hygiene strategies.

Rationale

The methods used to promote hand hygiene

1. Nosocomial infections

Rationale

The most common infection transmitted through unhygienic hands in the ICU

1. Hand hygiene and cross-infections.

Rationale

Determining hand hygiene and the relationship with cross infections

In summary, studies consistently show that better hand hygiene reduces the risks of cross contamination and nosocomial infections in Hospitals. Since most of the cross infections are thought to be transmitted through the dirty hands of healthcare workers, an assessment of the knowledge, attitude and practice of them is also necessary. Hospital-acquired infections carry a serious and real threat to all the patients admitted to hospitals, hence the assessment of healthcare worker’s hand hygiene practices is equally very significant.

Part 2 Literature Review: Hand washing and Hospital-Associated Infections

Most hospital associated infections are alleged to be transmitted via the hands of healthcare providers mainly through direct contact when the medical practitioner’s hands transfer the pathogens between individuals or between an environmental reservoir and an individual (Al-Khawaldeh, Al-Hussami, & Darawad, 2015). The purpose of this literature review is to find out whether there is sufficient evidence to indicate the need for further research on hand washing with regards to the infections that patients are susceptible to in the case of contaminated contact. The evidence from the various studies and nursing journals were carefully assessed to ensure that salient information regarding the research study area were present and were relevant to the study. The researcher took into consideration the ethical issues that are involved in research. The identities of the sample population were not released at any given time and they gave consent for the use of the information retrieved from them (Newcomb, 2010). Furthermore, most of the information used was from journal articles that allow for others to reference the works and findings of the research and, thus, the researcher could include the research material in the literature review (Fouka & Mantzorou, 2011).

Synthesis on the Current State of Knowledge

Despite the relative simplicity of hand hygiene procedure, the adherence rates to the standard recommendations remain unacceptably low; well below 50% (Bukhari et al., 2011). The reasons for non-compliance with hand washing are low staff to patient ratios, lack of appropriate hand washing equipment, insufficient knowledge about risks and procedures, allergies to some hand washing products, the casual attitude of healthcare practitioners (HCPs) and time factors (Pfoh, Dy, & Engineer, 2013). Patients are likely to suffer infections that arise from inconsistent hygiene practices especially those that are supposed to undergo an operation and have undergone a surgical operation.

The United Stated Department of Infectious Diseases estimated the incidence of hospital-acquired infections by 4.5% and with a 5% fatality in 2014 translating to a huge economic impacts (Al-Khawaldeh et al., 2015). One of the main contradictions is the fact that; despite the numerous hand washing guidelines that have been adopted by a majority of health facilities, the compliance by the health care providers remains low despite the practice being one of the simplest and most effective ways of preventing hospital-acquired infections (Bukhari et al., 2011). Some studies point of knowledge, attitude and practice as the primary factors affecting hand hygiene practices while other researches show that even if the healthcare workers from some developing countries would love to adopt best practices for hand hygiene, financial resources is a major factor (Bukhari et al., 2011; Pfoh, Dy, & Engineer, 2013)

In the recent past, studies in Croatia indicated that when it came to general hygiene especially hand washing when caring for patients at the health care centers most of the nurses and other health care providers did not meet the set of the World Health Organization (WHO) hygiene standards (Krleza et al., 2015). In addition, the inconsistent aseptic handling of capillary blood sampling especially dirty and infected hands reduced the chances of getting accurate analysis from the blood sample tests carried out (Krleza et al., 2015). Consequently, recommendations for promotion of hygiene are proposed by the researchers that include washing of the hands so as to reduce contamination of the blood samples that are collected.

Research also indicates that every year at least 290 000 surgical site infections are caused by the health care associated infections (Tsai & Caterson, 2014). Every year at least 1.7 million patients suffer tertiary infections that are as a result of health care associated infections. Furthermore, the results indicate that the health care system spends at least $45 billion every year on the treatment of surgical site infections that are caused due to health care associated infection (Tsai & Caterson, 2014). These statistics are staggering in terms of the amount of money that is spent on resultant infections that can easily prevented. Furthermore, hand washing is considered as one of the major causes of surgical site infections especially during post-operation health care provisions (Tsai & Caterson, 2014). Most of the health care officials are usually overwhelmed with the long hours of working shifts that some of the essential aseptic procedures are overlooked during caring for the patients’ wounds (Aiken, Karuri, Wanyoro, & Macleod, 2012).

According to Aiken et al (2012), most of the surgeries carried out in Sub- Saharan Africa are usually high risk because of the challenges that the health care providers face when it comes to maintenance of hygiene in the course of their work. Furthermore, the research indicated that some of the disinfectants that are to be used pre and post operation are not readily available given the high costs health centers incur when purchasing them (Kargupta et al., 2015). Alternatives such as alcohol and other aerosolized forms of disinfectants would be more appropriate in disinfecting the hands because they are readily available and are abundant in quantity. Therefore, it was suggested that the hospitals resort to using some of the cheap methods of disinfecting their instruments and well as using alcohol runs as hand wash given that it is cheap and it is readily available (Aiken et al., 2012). Furthermore, during post-operation care hygiene is paramount given that it hastens the recovery of patients and it further reduces their susceptibility to surgical site infections that are the key cause of some of the mortality cases witnessed in Sub Saharan Africa (Aiken et al., 2012)

Intravenous medication delivery has also been noted to suffer contamination especially given that some of the health care providers practice inconsistent aseptic techniques (Moureau & Flynn, 2015). Aseptic techniques include washing of the hands, disinfection of the needleless connectors, and use of anti-infective agents so as to reduce the risk of contamination; intravenous infections that have occurred as a result of contamination of the needleless connectors (Moureau & Flynn, 2015). The fact that the intravenous medication delivery is directly in contact with the veins of a person it increases the chance of infections that can be severe and in some cases fatal; therefore, it is important for consistent aseptic techniques to be carried out so as to ensure that the cases of contamination of intravenous medication delivery reduced to a minimum (Moureau & Flynn, 2015).

Preliminary Conclusions

This study has the primary objective of identifying and assessing the behaviors and factors affecting the practice of a simple intervention that is “hand hygiene” as practiced by healthcare practitioners (Davies, 2011). The study question is; Does hand washing and appropriate staff dressing among the surgical ward nurses reduce cross infection during patient management? The answer is yes, as the litterature review of the studies listed above demonstrated so. Research identifies the factors that motivate and those that affect the hand washing practice among health care providers (Davies, 2011). The gaps identified are meant to assist the healthcare management team and infection control units to develop appropriate measures for the implementation of hand washing policies and a translated reduction in the rates of hospital acquired infections (Davies, 2011).

In summary, there is a need for strategies that emphasize or remind the health care practitioners about hand washing; these include pinning of charts about hand washing at strategic points, provision of sufficient hand hygiene products, periodic classes on hand washing and an introduction of penalties for non-compliance.

Literature Review Summary Table

Part 3: Translating Evidence Into Practice

The PICOT Question and Its Significance to Nursing Practice

The primary objective of this study was to identify and assess the factors and behaviors that affect the practice of a clinical intervention that is “hand hygiene” as observed in the healthcare environment. The PICOT question is; Does hand washing, and appropriate staff dressing among the surgical ward nurses reduce cross infection during patient management? This research intended to identify the factors that affect the practice of hand hygiene among healthcare workers, while also looking at the factors that motivate the compliance to hand hygiene practice. The identified gaps are useful for the researchers to make recommendations to the infection control units and health management teams to initiate and enforce appropriate measures for implementing hand hygiene policies in the act of ensuring the reduction of hospital acquired infections that are caused by poor hand hygiene (Bukhari et al., 2013).

Millions of patients across the world are victims of healthcare acquired infections each year. These infections cause severe illnesses, prolonged length of hospital stay, disabilities and consequential costs to the healthcare system, the patients, and their families (Aiken, Karuri, Wanyoro and Macleod, 2012). Hand hygiene is a simple and single most effective measure for preventing hospital-acquired infections, but as simple as it may be, the compliance of health care providers to the practice of hand hygiene remains a problem, and this is the background of the study (Storr & Kilpatrick, 2013).

Literature Review: Summary of the Findings for the Selected Article

The study assesses evidence from various researches and nursing journals to obtain a comprehensive and significant information concerning the study area and what is relevant to the study. In a study by Bukhari et al., (2011), it was reported that despite the consensus that hand hygiene procedure is relatively simple, the adherence rates to the recommended standards of practice remain unacceptably low, way below 50%. The study's findings report that the reasons for hygiene hand non-compliance are a lack of appropriate hand washing equipment, low staff to patient ratio, allergies of some hand washing products, insufficient knowledge concerning the effects of poor hand hygiene, time factors and the attitude of health care practitioners (Bukhari et al., 2011). Patients, especially the surgical wards, are more exposed to the inconsistencies of hand hygiene practices.

Al-Khawaldeh et al., (2015) study referred to the estimates by the United States Department of Infectious Diseases report for 2014 which found that the incidence of healthcare-acquired infections stood at 4.5% and fatalities at 5%. The study also highlighted the contradiction of the fact that, the compliance to the numerous hand hygiene guidelines remains low despite the adoption of the practice by some healthcare facilities. Al-khawaldeh and his colleagues discover the fact that attitude, knowledge and practice are the primary factors influencing hand hygiene practices. Besides, the study indicates that healthcare workers in developing countries are affected by additional factors such as lack of financial resources and hand hygiene products.

Also, Aiken, et al, (2012) highlighted that some disinfectants utilized during and after surgical procedures are not usually available since they are highly expensive to purchase and the health institution might not be able to meet these costs. During the procedure of post operation care, hygiene plays a huge role since it hastens the process of recovery of the patient and also reduces their chances of being infected by the surgical site contaminants. These infections are some of the numerous mortality cases that have been experienced in most developing nations. In the evidence-based research, it clearly showed that the various gaps in hygiene practices have helped the health care sector and infection control units in the development of extraordinary measures for the process of integrating effective hand washing policies and has also translated reduction in the rates these hospital acquired infections occur (Bukhari et al, 2011).

The Identified Evidence-based Practice and its Contribution to Better Outcomes

Patients have suffered from diseases that have arisen from poor hygiene practices especially those that need to undergo operations but have opted for surgical operations (Aiken et al., 2012). Also, these infections have led to several diseases; prolonged hospital stays and also instances of severe illness that have added hospital expenses to their families, the patients and also the healthcare institution (Al Khawaldeh et al., 2015; Bukhari et al., 2013). Hospital-acquired infections have also posed huge threats to individuals admitted to these facilities. The bacteria and pathogens from, the hands of healthcare workers have readily been transmitted to patients. Hence, the hand hygienic practices have enormously reduced this chance (Aiken at al., 2012). The evidence-based research framework for hand hygiene is available and transparent for all relevant officials; however, the compliance issues have increased since they have remained considerably low (Bukhari et al., 2013).

Hand hygiene compliance, especially in the healthcare environment, is very vital for the prevention of healthcare associated infections. The reviewed literature report that pathogen transmit via the hands of healthcare workers is one of the main sources of healthcare acquired infection that can be prevented by application of proper hand hygiene practices (Al-khawaldeh et al., 2015; Bukhari et al., 2013). Nosocomial infections are the leading cause of infection, especially in the ICU, but the findings that indicate low compliance rates create a worrying trend (Huis et al., 2011­).

Estimations and studies conducted by the World Health Organization (WHO) indicate that at least 1.4 million patients are affected by healthcare acquired infections at any given time on the global scale Pittet et al, 2009). Hospital acquired infections are the leading causes of morbidity and mortality in the surgical units. Effective hand hygiene practice translated into action can avert most of the cases of healthcare-acquired infections (Huis et al., 2011­).

Strategy for Disseminating Evidence-Based Practice

The practice of hand hygiene is aimed at maintaining cleanliness of the hands and keeping them free from pathogens or removing the amounts of pathogens before touching any patient, surface or performing any medical procedure. Proper hand hygiene practice helps to prevent cross infections in the healthcare environment (Al-khawaldeh et al., 2015). The strategies that will ensure an easy adoption of the practice should consider applying an easy to use technique, timely access, and a product that is friendly to the skin of the user (Al-khawaldeh et al., 2015). The promotion of hand hygiene practice calls for the use of a multimodal strategy. Some of the recommended strategies include audit and performance of feedback practices, education of healthcare workers, increased supply of water and hand hygiene products, the use of automated sinks, use of reminders at strategic points and use of alcohol-based hand rub where the hands are not visibly soiled to save time (Al-khawaldeh et al., 2015; Bukhari et al., 2013). The best procedure for disseminating this research is through reviews. This information can be communicated through hygiene policy classes, seminars and also important health officials that focus on the provision of adequate hand hygiene products and also introduce severe penalties for noncompliance of these health practitioners (Aiken et al., 2012).

Also, formations of dissemination partnerships that provide a link to all the relevant stakeholders that enhance the sharing of knowledge concerning the compliance guidelines and also the importance of hand hygiene in health institution (Keough, and Tanabe, 2011). Several varieties of implementation, such as utilizing a change champion in the health facility, can address the challenges that will hinder the implementation process. This individual can formulate and clearly highlight the importance of implement multifaceted hygiene projects that would reduce these risks that occur due to non-compliance and also negligence from the health officials (Bukhari et al., 2013). These strategies are highly relevant especially in the process of embedding innovations into the overall health procedures that are ongoing in the enterprise.

A call for behavior change and positive attitude is also necessary if the above strategies are to be implemented (Katapondi & Northouse,2011).

Summary of the Project

The study presents clear evidence that non-compliance with hand hygiene practice which leads to cross infections can be prevented by a simple and most effective way that is proper hand hygiene. The project analyzed broad issues through important questions and analyzed the rationale of the importance of hand hygiene in health institutions. Also, the project evaluated the evidence that indicated the necessity for further research concerning hand hygiene especially considering the risks posed to patients when they come into contact with the contaminated object (Bukhari et al., 2013).

Also, the project has clearly shown how these infections have led to numerous illnesses, long-term disabilities and also prolonged hospital stays and increased the overall costs to patients, families and also the healthcare institution. Hand hygiene is a vital procedure in the reduction of several infections acquired in healthcare (Aiken et al., 2012). There have emerged several compliance issues among the healthcare providers. No matter the agent utilized in the maintenance of hand hygiene in health institution, there is only a single goal which is the prevention of infection (Aiken et al., 2012). Effective surgical scrubs are one of the essential strategies for disease prevention. Various tools and equipment must be used to promote and enhance the protection against bacterial infection. It becomes a priority for healthcare management to assist personnel in comprehension of the consequences of failures in hand hygiene as they relate to prevention of disease (Pittet et al, 2009). It is essential that the healthcare workers maintain high health standards at the workplace (Huis et al., 2013). This means there is need to have good hygiene practices to prevent surgical site infections. Hand washing can be one method of reducing these after infections (Bukhari et al., 2012). However, secondary methods such as the use of antibiotic prophylaxis can be used to greatly reduce the possibility of contracting most of the surgical site infections. Dissemination and communication methods used must reach out for every member of the identified health sector to ensure maximum improvement.

References

Aiken, A. M., Karuri, D. M., Wanyoro, A. K., & Macleod, J. (2012). Interventional studies for preventing surgical site infections in sub-Saharan Africa. International Journal of Surgery, 242-249. Doi: 10.1016/j.ijsu.2012.04.004

Al-Khawaldeh, O., Al-Hussami, M., & Darawad, M. (2015). Influence of Nursing Students Handwashing Knowledge, Beliefs, and Attitudes on Their Handwashing Compliance. Scientific Research Publishing. Doi: http://dx.doi.org.ezp.waldenulibrary.org/10.4236/health.2015.75068 

Bukhari, S., Hussain, W., Banjar, A., Almaimani, W., Karima, T., & Fatani, M. (2011). Hand hygiene compliance rate among healthcare professionals. PubMed - NCBI. Ncbi.nlm.nih.gov. Retrieved 1 April 2016, from http://www.ncbi.nlm.nih.gov/pubmed/21556474

Davies, K. S. (2011). Formulating the evidence-based practice question: A review of the frameworks. Evidence-Based Library and Information Practice, 6 (2), 75–80. Retrieved from https://ejournals.library.ualberta.ca/index.php/EBLIP/article/viewFile/9741/8144

Fouka, G., & Mantzorou, M. (2011). What are the major ethical issues in conducting research? Is there a conflict between the research ethics and the nature of nursing? Health Science Journal, 3-14. Retrieved from the Walden Library database

Huis, A., Schoonhoven, L., Grol, R., Borm, G., Adang, E., Hulscher, M., & van Achterberg, T. (2011). Helping hands: A cluster randomised trial to evaluate the effectiveness of two different strategies for promoting hand hygiene in hospital nurses. Implementation Science, 6(1), 101. http://dx.doi.org/10.1186/1748-5908-6-101

Kargupta, R., Hull, G. J., Rood, K. D., Galloway, J., Matthews, C. f., Dale, P. S., & Sengupta, S. (2015). Foaming Betadine Spray as a potential agent for non-labor-intensive preoperative surgical site preparation. Annals of Clinical Microbiologicaland Antimicrobials. doi: 10.1186/s12941-015-0076-2

Katapodi, M. C., & Northouse, L. L. (2011). Comparative effectiveness research: Using systematic reviews and meta-analyses to synthesize empirical evidence. Research & Theory for Nursing Practice, 25 (3), 191–209. DOI: http://dx.doi.org/10.1891/1541-6577.25.3.191

Keough, V. A., & Tanabe, P. (2011). Survey research: An effective design for conducting nursing research. Journal of Nursing Regulation, 1(4), 37–44. doi:10.1016/S2155-8256(15)30315-X

Krleza, J. L., Dorotic, A., Gruznov, A., & Maradin, M. (2015). Capillary blood sampling: national recommendations on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine. Biochemia Medica, 335-358. DOI: 10.11613/BM.2015.034

McGonigle, D., & Mastrian, K. G. (2012). Nursing informatics and the foundation of knowledge (Laureate Education, Inc., custom ed.). Burlington, MA: Jones & Bartlett Learning.

Moureau, N. L., & Flynn, J. (2015, May 14). Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review. Nursing Researcj and Practice. Moureau, N. L., & Flynn, J. (2015, May 14). Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review. Nursing Research and Practice. Doi: http://dx.doi.org/10.1155/2015/796762

Newcomb, P. (2010). Evolving fairness in research on human subjects. Journal of Child and Adolescent Psychiatric Nursing, 123-124. doi: 10.1111/j.1744-6171.2010.00233.x

Pfoh, E., Dy, S., & Engineer, C. (2013). Interventions To Improve Hand Hygiene Compliance: Brief Update Review. Agency For Healthcare Research And Quality (US). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK133371/

Pittet, D., Allegranzi, B., & Boyce, J. (2009). The World Health Organization Guidelines on Hand Hygiene in Health Care and Their Consensus Recommendations. Infection Control and Hospital Epidemiology, 30 (7), 611-622. http://dx.doi.org/10.1086/600379

Polit, D. F., & Beck, C. T. (2012).  Nursing research: Generating and assessing evidence for nursing practice (Laureate Education, Inc., custom ed.).Philadelphia, PA: Lippincott Williams & Wilkins.

Royal Pharmaceutical Society. (2014). Hand washing plugged as a way of cutting infection rates. The Pharmaceutical Journal. http://dx.doi.org/10.1211/pj.2014.11137491

Storr, J. & Kilpatrick, C. (2013). Improving adherence to hand hygiene practice. Nursingtimes.net. Retrieved 24 April 2016, from http://www.nursingtimes.net/download?ac=1279774

Tsai, D. M., & Caterson, E. J. (2014, October 11). Current preventive measures for health-care associated surgical site infections: a review. Patient Safety in Surgery. Doi: 10.1186/s13037-014-0042-5

World Health Organization. (2009). WHO guidelines on hand hygiene in health care: first global patient safety challenge. Clean care is safer care. World Health Organization. Retrieved from: http://www.who.int/gpsc/5may/tools/who_guidelines-handhygiene_summary.pdf