Hand Hygiene Compliance of Nurses


A Systemic Review on the Effectiveness of Interventions to Improve Hand Hygiene Compliance of Nurses in the Hospital Setting

Please write in simple academic language.

Word count 2500

Assignment topic

The aim of critical appraisal is to ensure the clinical research articles are reliable, valid and applicable before it is applied to a patient. In this assignment, you are required to critically appraise a systematic review paper using the criteria given in the rubric.


You must select one systematic review paper provided below and indicate the title of the systematic review paper on the title page of your assignment


A Systematic Review on the Effectiveness of Interventions to Improve Hand Hygiene Compliance of Nurses in the Hospital Setting (I have uploaded the paper)


Marking Guide for Assessment



Introduction(marks 5)


• Students provide a clear and adequate description and discussion of the topic of interest in their professional practice.


Review problem/focus/ question (marks 5)


Population studied …who are the participants

Interventions given ….eg staff training,environmental assessment, physical activities and exercises,paraphrase the statement which have been discussed in your paper

• Outcomes considered..type of outcome measures or how the outcome is evaluated


Literature search/ Review(marks 5)


• Appropriateness of papers relevant to review question….was a comprehensive search performed

• Appropriate study design …..what is the study design, are they appropriate.

• Usage of appropriate database and outside resources


Quality of the review (marks 5)


• Did the authors assess the quality/rigour of the including/excluding studies?


 Data synthesis


• Are the results of the review combined? …(optional.)only for meta-analysis quantitative study

• Were the results of the individual studies displayed?

• Were the similarities among the individual studies included?

• Were similar results from different studies considered?

• Were variations in results discussed with reasoning?


Results (marks 5)


• What are the overall results/bottom line (e.g. numerical) of the review? ..what are the overal result.publication bias if any,

• Precision of the results (confidence intervals) ..accuracy of the result.


Discussion (marks 10)


• Is the result of the review applicable to the local population?

• Did the review focus on all the important outcomes?

• Advantages (benefits) and disadvantages (harms, costs etc.) of the results of the review

• Recommendations for future research


Presentation (marks 10)


• Headings in the body of the paper are clearly labelled and information under each heading relates to the heading

• Logical and sequential arrangement of explanations and descriptions

• Conclusion provides a summary of the paper; no new information is provided


APA Format and References (marks 5)


• Grammar, spelling and punctuation

• Paper meets APA guidelines regarding margins, font, references, etc. All content follows current APA writing guidelines


According to our college, whatever we are writing, except common knowledge, we have to provide in-text citation, and bibliography.Therefore, if you are giving any facts or other than common knowledge please provide references. We can have up to 20 references.



A Systemic Review on the Effectiveness of Interventions to Improve Hand Hygiene Compliance of Nurses in the Hospital Setting


Hand hygiene practices are among the key ways of preventing the prevalence of health associated infections (HAI) (Caselli et al., 2018). For the critically ill patients, HCAI could lead to extended hospitalization, morbidity, mortality and increased expenditure for the healthcare facility (Bora, Bahrami& Hosseini, 2018). Often, patients leave the hospital with new infections that they did not have before coming in for treatment. According to the WHO (nd), all healthcare workers, caregivers or personnel who come in contact with patients should practice hand hygiene. Healthcare providers are encouraged to rub their hands with an alcohol-based formulation as a routine hand-cleaning procedure (“Hand Hygiene”). This is the most preferred routine that ensures hygienic hand antisepsis. Additionally, healthcare providers are advised to clean their hands with water together with soap when their hands are contaminated with bodily fluids including blood and other spore-forming pathogens (McLaws, 2015). With increasing rates of occurrence of HCAI, healthcare providers including nurses must device techniques to control and prevent these infections.

Poor hand hygiene results in several risks. Healthcare associated infections (HAIs) are a great threat to patients. As such, HAIs contributes to the increased economic burden of healthcare (Jia et al., 2011). Among the risks associated with HAIs includes the spread of microorganisms on healthcare worker’s hands. HAIs can be greatly reduced by using efficient and effective prevention techniques and practices. Improving hand hygiene compliance among healthcare professionals has significant effects on the reduction of HAIs. Research shows that maintaining hand hygiene compliance is associated with human behaviour, leadership and organizational culture (Grayson et al., 2011). A study carried out by Grayson et al. (2011) analysed and reported outcomes of the National Hand Hygiene Initiative (NHHI) implemented in several Australian hospitals. The hand hygiene program relied heavily on the standards and principles set by the World Health Organization and its recommended 5 moments of hand hygiene program. The results of the program showed improvements in HHC among healthcare providers in Australia (Grayson et al., 2011). To achieve hand hygiene compliance, a multifaceted approach must be adopted by healthcare providers.

One of the most efficient techniques to control HCAI is ensuring compliance with hand hygiene practices among care givers in the hospital (Zhao, Yang, Huang & Chen, 2018). Nurses’ hands come into contact with many surfaces in the hospital. As such, they act as the primary causative agent of the transfer of germs in the hospital (Bora, Bahrami& Hosseini, 2018). Several studies have been published on the effectiveness of interventions designed to ensure hand hygiene compliance (HHC) among healthcare professionals. All the reviews highlight on the role that nurses play to improve HHC in the healthcare facility. Nurses come into contact with patients a majority of the time. Therefore, they have an important role to play in maintaining hand hygiene (Doronina et al., 2017). This highlighted systemic review analyses the effects of interventions designed to ensure hand hygiene compliance among nurses in the hospital setting.

Review Question

Population Studied

Th population of interest analysed by Doronina et al (2017) includes nursing personnel comprising of registered nurses having either a bachelor’s or a college degree in nursing. Additionally, the study incorporated advanced practice and licensed practical nurses, patient care attendants and nursing assistants. The study also addresses all nursing personnel as nurses (Doronina et al. 2017).

Types of Studies

The studies selected were limited to randomized control trials (RCT), interrupted times series (ITS) and controlled before and after studies (CBAs). The study also implemented interventions proposed by the Cochrane Effective Practice and Organization of Care Group (EPOC) (Doronina et al., 2017). The proposed interventions were used to investigate the effectiveness of interventions. The studies selected had to clearly highlight their interventions (Doronina et al., 2017). Likewise, the interventions must have been collected at three different collection points. Studies included in the review had to have statistical data on effect of interventions on nurses. Studies whose participants were nurse students were not included in this analysis (Doronina et al., 2017)

Interventions given

The researchers offered interventions that targeted hand washing practices in hospitals. Additionally, the interventions considered were either included in the hospital’s hand hygiene compliance practices or as one of the elements (Doronina et al., 2017). The study also included interventions related system changes, education, workplace reminders and feedback, universal precautions and infection control. However, studies that were conducted outside the hospital setting were excluded (Doronina et al., 2017). Studies that also stated that they used direct observation as the only form of intervention used were also excluded.

Outcomes Considered

Being a system review, several studies were analysed. The studies that offered several criteria designed to analyse the effect of specific interventions on HHC were included. Studies that used electronic monitoring techniques like video recording were considered in the review (Doronina et al., 2017). Likewise, the review analysed studies that used direct forms of observations to measure HHC rates. Studies that used unobtrusive methods of observation are more preferred since they avoid the development of the Hawthorne effect. This effect is the resulting awareness created when study participants are investigated and the possible impact on their behaviour analyzed (McCambridge, Witton &Elbourne, 2015). Other factors that were eligible for inclusion were the amount of hand sanitizer used which was measured before and after hand washing activities. However, studies that used self-report to measure HHC were excluded due to the tendency of having an inaccurate perception of oneself (Doronina et al., 2017).

Literature Review

            The purpose of the systemic review was to identify interventions that target hand hygiene compliance and improvement among nurses. To achieve this goal, the study carried out a systemic review of several interventions targeting hand hygiene interventions among nurses in hospitals (Doronina et al., 2017). The study used reporting items for systemic reviews and Meta-analyses to analyse available interventions to improve HHC. The review carried out a search of nursing and health literature. Additionally, the systemic review used data from Medline Global Health to supplement data obtained from other studies. During the study selection process, the researchers carried out an electronic search of all relevant articles with regards to the research question. After identifying approximately 413 articles, the researchers then removed duplicate articles. 303 articles remained where 7 were from a single systemic review while the other 299 were from electronic records. The researchers also excluded 5 articles mainly due to: study participants being nursing students or respiratory therapists. Other studies were excluded due to lack of results for nurses, unavailability of full texts and self-reports of outcome measures. Overall, six studies were included in quantitative synthesis. Three of the studies were randomized control trials; one of the studies was a controlled before and after study and two studies were interrupted times series (Doronina et al., 2017). As the starting point, the review analysed a study on interventions designed to improve HHC among care givers. To build on this, the review also analysed studies that provided relevant data on the effectiveness of interventions to improve hand hygiene among nurses. 63 studies were analysed from Medline, 100 studies from CINAHL, 37 from Global Health and 213 studies from Embase source.

Quality of the Review

The review used a two-stage search strategy to analyse relevant data. First the review analysed seven key studies containing data on HHC among nursing personnel. Secondly, the review carried out a search on electronic databases such as the Cochrane central register of controlled trials, Medline and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). The review included studies published from February 2014, to 2017 therefore ensuring that newer studies are included (Doronina et al., 2017). In total, 413 articles were identified by a team of three researchers. The reviewers screened abstracts and titles to assess eligibility based on parameters selected.  During the data collection process, eleven studies were identified and included in a secondscreening process. The selected studies were also assessed for risk of bias. The study used specific inclusion and exclusion criteria to analyse the selected studies. Some of the criteria used include; blinding of study participants and the researchers, cross-contamination existing between control groups and experimental groups, addressing incomplete data and intervention effects on data collection (Doronina et al., 2017). The results of the review are combined based on their interventions. Due to any discrepancy arising between the researchers, data accuracy was verified independently.


Overall Results

Among the studies analysed, two of themanalysed single component interventions to improve HHC. Some of the single components analysed by the two studies include education and training to improve hand hygiene. In the training exercises carried out epidemiology and universal precautions were among the key topics addressed (Doronina et al., 2017). Two of the studies analysed used both education and other strategies including audits as interventions. A separate study analysed the impact of electronic reminders and feedback on overall HHC in the hospital setting. Other studies chose to combine interventions in a multidimensional strategy. Some of the strategies that were combined include education, training, electronic reminders, feedback, incentives, setting goals and the direct participation of group leaders (Doronina et al., 2017). The analysis provides a table containing a summary of the overall results.

The review was subject to a certain level of publication bias because only English-language articles were analysed. Since there was lack of explicit ample size power analysis, a large proportion of the studies had issues of generalizability (Doronina et al., 2017).

Precision and Expression of the Results

            The results of the review were presented in table highlighting the percentage of the effect of each intervention on HHC. For studies that used education and feedback as interventions, the baseline effects of the intervention on HHC was 81%. Four weeks after the two interventions were introduced, the impact on HHC increased significantly to 86% for education interventions and 92% for feedback interventions (Doronina et al., 2017). For studies that used electronic reminders as interventions, there were significant changes in the amount of hand sanitizer used which translates to significant improvements in hand hygiene. Articles that used education as the main intervention also reported improvements in HHC among nurses. More nurses performed essential documentation and wore personal protective equipment effectively. However, the studies call for improvement in hand documentation techniques. Additionally, for the studies that used education and training as interventions, there was profound increase in HHC both in the short run and the long run. The studies also observed that nurses were inclined to maintain hand hygiene immediately after coming in contact with patients. However, compliance was low before an aseptic task was conducted or when moving from a dirty part of the body to a clean one. HHC increased from 51% to 86% before patient contact. Likewise, HHC increased from 75% to 91% after patient contact (Doronina et al., 2017).  Likewise, articles that used feedback and education also experienced significant improvements in HHC in both the control and the test subjects.



Overall, the review has confirmed that multimodal, dual or single component interventions are effective in ensuring hand hygiene compliance among nurses in the hospital setting. The review also notedthat studies which used combined interventions demonstrated relatively high rates of HHC and increased sustainability (Doronina et al., 2017). Strategies that incorporated reminders, feedback, education, product availability and availability of support teams had the best results. Feedback combined with education also showed high results compared to studies that used either education or feedback interventions. Likewise, after analysing the studies, the review noted that failure of HCC in hospitals is not the sole responsibility of personnel only but a combination of failures in systems in the hospitals (Doronina et al., 2017).

Implications for Practice

All healthcare professionals including nurses should strive to promote and maintain HHC in their healthcare facilities. Compliance can be maintained by following the WHO recommendations for hand washing (Vikke et al., 2019). According to the WHO, hands are the primary pathways through which germs are transmitted during healthcare. Hand hygiene is therefore a critical measure to reduce transmission of germs and promote wellness (“Hand Hygiene”). In hospitals, WHO recommends that clinicians “clean their hands before touching a patient, before clean or aseptic procedures, after body fluid exposure risk, after touching a patient and after touching the patient’s surroundings” (“Hand Hygiene”). According to the systemic review, a combination of interventions including HHC education, visual reminders and support from team leaders are critical in guaranteeing success of HHC. In addition to offering these interventions, healthcare facilities should set goals, provide rewards and track accountability to ensure HHC.

Advantages and Disadvantages of the Results

            One of the main advantages of the review is the fact that it is the first study to focus mainly on nurses. However, the study has several disadvantages including; lack of information about blinding of participants and researcher. Additionally, a majority of the studies lack randomization while others had long follow-up periods of more than six months (Doronina et al., 2017). The studies analysed also lacked robust methodological quality while others had different measuring criteria for their HHC. Since a majority of the studies analysed used direct observation to measure HHC, the occurrence of the Hawthorne effect was relatively high. Therefore, there is a high likelihood for overestimation and associating it to the interventions used (Doronina et al., 2017). Lastly, the study only analysed articles written in English thus excluded other relevant studies in other languages. The study recommends the incorporation of discussions within the healthcare system and hand hygiene compliance interventions about personal control, intentions and motivations.


As the review shows, interventions designed to improve HHC among nurses are successful in reducing instances of disease transfer in hospitals. Health associated infections (HAI)- are one of the greatest challenges in the hospital setting. With increased rates of mortality and morbidity, extended periods of hospitalization and increased expenditures for healthcare facilities, infection control strategies should be designed to prevent infections. Maintaining hand hygiene practices among nurses significantly prevents the spread of infections. As the systemic review notes, using single-component interventions like education, electronic reminders or feedback highly improves HHC in hospital settings. However, the review demonstrates greater improvements when these interventions are combined. Likewise, goal setting, accountability and offering reward incentives also improved HHC. The review calls for better interventions to address the low levels of HHC among nurses in hospitals.




Bora, M.M., Bahrami, M. & Hosseini, M. (2018). A Survey of Nurses’ Compliance with Hand Hygiene Guidelines in Caring for Patients with Cancer in a Selected Centre of Isfahan, Iran, in 2016. Iranian Journal of Nursing and Midwifery Research, 23(2), 119-124. Doi: 10.4103/ijnmr.IJNMR_228_16

Caselli, E., Brusaferro, S., Coccagna, M., Arnoldo, L. et al. (2018). Reducing Healthcare-associated Infections Incidence by a Probiotic-based Sanitation System: A Multicentre Prospective, Intervention Study. PLoS One, 13(7). Doi:10.1371/journal.pone.0199616

Doronina, O., Jones, D., Martello, M., Biron, A. Lavoie-Tremblay, M. (2017). A Systemic Review on the Effectiveness of Interventions to Improve Hand Hygiene Compliance of Nurses in the Hospital Setting. Journal of Nursing Scholarship, 49(2), 143-152. Doi: 10.1111/jnu.12274

Grayson, M.L. et al. (2011). Outcomes from the First 2 Years of the Australian National Hand Hygiene Initiative. Medical Journal Australia, 195(10), 615-619. Doi: 10.5694/mja11.10747

“Hand Hygiene: Why, How & When?”. World Health Organization. Retrieved from https://www.who.int

Jia, H. et al. (2019). Impact of Healthcare-Associated Infections on Length of Stay: A Study in 68 Hospitals in China. BioMed Research International, 2019, 7. Doi: 10.1155/2019/2590563

McCambridge, J., Witton, J. &Elbourne, D.R. (2015). Systematic Review of the Hawthorne Effect: New Concepts are Needed to Study Research Participation Effects. Journal of Clinical Epidemiology, 67(3), 267-277. Doi: 10.1016/j.jclinepi.2013.08.015

McLaws, M. (2015). The Relationship Between Hand Hygiene and Health Care-Associated Infection: its Complicated. Infection and Drug Resistance, 8, 7-18. Doi: 10.2147/IDR.S62704

Vikke, H.S. el al. (2019). Compliance with Hand Hygiene in Emergency Medical Services: an International Observational Study. Emergency Medical Journal, 36(3). Doi: 10.1136/emermed-2018-207872

Zhao, Q., Yang, M.M., Huang, Y.Y. & Chen, W. (2018). How to Make Hand Hygiene Interventions More Attractive to Nurses: A Discrete Choice Experiment. PloS One, 13(8). Doi: 10.1371/journal.pone.0202014


























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