Capstone on Hand Hygiene in the Operating Room: Chapter 2: Review of the Literature

Capstone on Hand Hygiene in the Operating Room: Chapter 2: Review of the Literature
Credible Sources
Hand hygiene compliance is the basis of infection control as supported by scientific research and national guidelines. Although the practice is fundamental, maintenance and improvement are always difficult due to low compliance rates. To solve the issue, numerous pieces of evidence are available to guide the implementation of practices that can improve hand hygiene compliance. Appendix A of my research contains 30 credible sources that explore hand hygiene practices in healthcare facilities. These sources provide information about the causes of poor hand hygiene compliance, strategies to improve the practice, the importance of improving hand hygiene practices, and barriers associated with hand hygiene compliance. The selected articles contain data that has been collected using different methods leading to different strengths of evidence. Additionally, the peer-reviewed articles were retrieved from different databases including CINAHL, Cochrane, PubMed, MEDLINE, and EMBASE except for the WHO national guidelines on hand hygiene in healthcare.

Table of Contents

Best Practices

Education and Training

Hand hygiene practices have been shown to be low both in developing and developed countries. Among the recommended practices to improve hand, hygiene is the use of educational measures and training of healthcare personnel (WHO, 2009). Education is critical to improving hand hygiene because it equips nurses, doctors, and other healthcare providers with skills on how to perform the practice effectively. Research conducted in Vietnam revealed that 70% of hand hygiene practices are done wrongly leading to an increased rate of HAIs (Phan et al., 2018). There is also supporting evidence that about 65% of healthcare professionals have little knowledge about the WHO hand hygiene guidelines and the majority have never attended an educational program on hand hygiene (Ahmed et al., 2020). Education and training can help increase self-monitoring practices during hand washing and it can boost the healthcare provider’s knowledge of diseases that can be prevented using the practice.

Multimodal Interventions

Quality improvement in healthcare can either use a single intervention method or multimodal approaches. Single interventions involve the use of one evidence-based practice to improve on a certain behavior or procedure while multimodal approaches use two or more evidence-based practices. Evidence indicates that hand hygiene compliance can best be achieved through the use of multimodal interventions (Rodriguez et al., 2015). Among the commonly used approaches include leadership commitment, surveillance of hand hygiene materials, utilization of reminders, educational interventions, and providing feedback about hand hygiene compliance rate. Sands and Aunger (2020) explain that multimodal approaches improve communication, openness, and increase interaction between healthcare teams leading to the achievement of high compliance rates. Additionally, multimodal interventions are preferred over single interventions because they can measure multiple aspects of hand hygiene compliance at the same time.

Professional Modeling

During hand hygiene practice in healthcare, factors that influence the behavior of healthcare workers are of great interest. The organizational leaders should act as role models to enable junior staff to follow suit. It is hypothesized that strict hand hygiene adherence by supervisor role models would improve the hand hygiene behavior of junior staff (Qasmi et al., 2018). Role models help improve the attitude of employees on hand hygiene and it keeps the leaders active to observe the practice on other healthcare workers. A multifaceted study conducted among students indicated that high hand hygiene compliance rates were achieved when role modeling intervention was used (Gould et al., 2017). Professional modeling is an important practice that helps keep employees active while increasing their self-awareness about the practice. Professional modeling capitalizes on the power of peer pressure whereby employees are likely to follow what their leaders or peers do.

Evidence Summary

Importance of Hand Hygiene Compliance

Hand hygiene compliance is evidently the most important factor to prevent the spread of healthcare-associated infections (HAIs). These infections make it difficult for the patient to recover and they increase hospital length of stay. It is observed that one in 31 hospital patients is affected by HAIs on any given day (Hillier, 2020). Decontamination using hand hygiene has proven effective in reducing infections and preventing the spread of disease. A systematic review conducted on the importance of hand hygiene indicated that it is critical in reducing HAIs. The review explained that hand hygiene compliance can be useful in reducing infections associated with the gastrointestinal tract and the respiratory system (Andriani & Nadjib, 2018). Other studies have focused on cost reduction and patient satisfaction aspects of the practice. Tan et al (2015) found out that hand hygiene compliance can reduce costs resulting from HAIs and can also increase patent satisfaction in the long run.

Strategies for Improving Hand Hygiene Compliance

Different strategies have been proposed to improve hand hygiene compliance among nurses including multimodal-directed approaches and individual interventions. Education and training are among the top available interventions to improve hand hygiene compliance (Dorinina et al., 2017). This approach is effective because it increases knowledge among healthcare workers while promoting self-awareness. While the practice can be promising, it is observed that it is a slow method of achieving hand hygiene compliance (Price et al., 2018). There is substantial heterogeneity in hand hygiene education and training among infection prevention and control professionals worldwide. Lack of experienced and trained healthcare workers on the aspect of hand hygiene could be among the problems contributing to poor hand hygiene compliance (Tartari et al., 2019). Evidence-based practice guidelines are in support of education and training to improve upon the practice. While training is recommended, the use of simulations in a practical bedside and hands-on approach greatly improves hand hygiene compliance.

Educational approaches to improving hand hygiene compliance in ICUs and operating rooms mainly address the frequency of handwashing, duration of hand hygiene, indications for hand hygiene, and efficacy of alcohol-based hand rub. A study conducted in Vietnam utilized the education approach using short videos, small group discussions, and role-playing to improve compliance to hand hygiene. It was observed that hand hygiene knowledge increased within a few sessions during the intervention (Phan et al., 2018). In conclusion, the researchers explain that educational hand hygiene can significantly improve compliance in clinical settings of high patient turnover. These findings are consistent with another study that identified a link between hand hygiene and professional role and status, social affiliation, modification of the work environment, and social norms (Sands & Aunger, 2020). Educational approaches are critical because they touch the psychological aspects of healthcare providers and are more likely to influence behavior change.

The increasing rate of healthcare-associated infections has led to prolonged hospital stays for patients and an increased economic burden on the healthcare system. Strong evidence suggests that the increasing rate of HAIs is caused by substandard hand hygiene practices (Musu et al., 2017). In the United States, data shows that over two million infections occur each year and hand hygiene is the only solution to decrease these infections. The standard hand hygiene compliance recommended by the WHO is 91% and above, but to the contrary, the average hand hygiene compliance among healthcare workers is 40% (Quilab et al., 2019). Observational studies conducted across the globe indicate that hand hygiene compliance is best achieved through the use of training and educational programs. Mageus et al (2015) indicates that other strategies such as the use of feedback, utilization of reminders, and storyboard projects can supplement the education and training interventions.

Strategies for improving hand hygiene in healthcare can be either short term or long term. An electronic search of articles from CINAHL, Cochrane, and EMBASE databases indicates that educational interventions, reminder systems, and ABHR availability are short-term interventions fr hand hygiene compliance (Gould et al., 2017). However, multimodal interventions which involve a combination of two or more serve as long term solutions to many organizations. The results of this study are consistent with a study conducted by Rodriguez et al (2015) which identified multimodal approaches as the most effective to improve hand hygiene compliance in ICUs. Another strategy included is the use of professional modeling whereby leaders or managers lead by example in hand hygiene compliance (Qasmi et al., 2018). This approach improves the attitude of employees and increases self-awareness which drives involvement in hand hygiene practices.

Recommendation

Hand hygiene is the primary action for preventing HAIs and the spread of drug-resistant bacteria. Compliance with hand hygiene protocols is important both to the healthcare providers and patients. In my organization, the problem of hand hygiene compliance in the operating room lies in aspects such as the use of soap to wash hands and following the recommended indications for hand hygiene. According to my assessment, the staff lacks basic education on hand hygiene and there is little reinforcement of the practice in the unit. To solve this problem, I recommend the use of an education and training intervention program because it is supported by evidence to improve hand hygiene compliance (Quilab et al., 2019). Special emphasis will be given to ways that microorganisms are transmitted, the indications for handwashing, the technique for hand hygiene, and the duration for hand washing as directed by the WHO (2009) guidelines.

References

Ahmed, J., Malik, F., Memon, Z. A., Bin Arif, T., Ali, A., Nasim, S., Ahmad, J., & Khan, M. A. (2020). Compliance and knowledge of healthcare workers regarding hand hygiene and use of disinfectants: A study based in Karachi. Cureus Journal of Medical Sciences, 12(2), e7036. https://doi.org/10.7759/cureus.7036

Alshehari, A. A., Park, S., & Rashid, H. (2018). Strategies to improve hand hygiene compliance among healthcare workers in adult intensive care units: A mini systematic review. The Journal of Hospital Infection, 100(2), 152–158.

https://doi.org/10.1016/j.jhin.2018.03.013

Andriani, Y., & Nadjib, M. (2018). The importance of implementation of hand hygiene practice in reducing healthcare-associated infections: A systematic review. KnE Life Sciences, 135-145. DOI: 10.18502/kls.v4i9.3565

Ataiyero, Y., Dyson, J., & Graham, M. (2019). Barriers to hand hygiene practices among health care workers in sub-Saharan African countries: A narrative review. American Journal of Infection Control, 47(5), 565–573.

https://doi.org/10.1016/j.ajic.2018.09.014

Butenko, S., Lockwood, C., & McArthur, A. (2017). Patient experiences of partnering with healthcare professionals for hand hygiene compliance: A systematic review. JBI Database of Systematic Reviews and Implementation Reports, 15(6), 1645–1670. https://doi.org/10.11124/JBISRIR-2016-003001

Chavali, S., Menon, V., & Shukla, U. (2015). Hand hygiene compliance among healthcare workers in an accredited tertiary care hospital. Indian Journal of Critical Care Medicine, 18(10), 689–693.

https://doi.org/10.4103/0972-5229.142179

Chhapola, V., & Brar, R. (2015). Impact of an educational intervention on hand hygiene compliance and infection rate in a developing country neonatal intensive care unit. International Journal of Nursing Practice, 21(5), 486–492.

https://doi.org/10.1111/ijn.12283

Doronina, O., Jones, D., Martello, M., Biron, A., & Lavoie-Tremblay, M. (2017). A systematic 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. https://doi.org/10.1111/jnu.12274

Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., & Taljaard, M. (2017). Interventions to improve hand hygiene compliance in patient care. The Cochrane Database of Systematic Reviews, 9(9), CD005186.

https://doi.org/10.1002/14651858.CD005186.pub4

Graveto, J. M. G. D. N., Rebola, R. I. F., Fernandes, E. A., & Costa, P. J. D. S. (2018). Hand hygiene: Nurses’ adherence after training. Revista Brasileira de Enfermagem, 71(3), 1189-1193. http://dx.doi.org/10.1590/0034-7167-2017-0239

Hillier, M. D. (2020). Using effective hand hygiene practice to prevent and control infection. Nurs Stand, 35(5), 45-50. DOI: 10.7748/ns.2020.e11552

Megeus, V., Nilsson, K., Karlsson, J., Eriksson, B. I., & Andersson, A. E. (2015). Hand hygiene and aseptic techniques during routine anesthetic care – observations in the operating room. Antimicrobial Resistance and Infection Control, 4(1), 5. https://doi.org/10.1186/s13756-015-0042-y

Mu, X., Xu, Y., Yang, T., Zhang, J., Wang, C., Liu, W., Chen, J., Tang, L., & Yang, H. (2016). Improving hand hygiene compliance among healthcare workers: An intervention study in a hospital in Guizhou Province, China. The Brazilian Journal of Infectious Diseases : An official publication of the Brazilian Society of Infectious Diseases, 20(5), 413–418. https://doi.org/10.1016/j.bjid.2016.04.009

Musu, M., Lai, A., Mereu, N. M., Galletta, M., Campagna, M., Tidore, M., Piazza, M. F., Spada, L., Massidda, M. V., Colombo, S., Mura, P., & Coppola, R. C. (2017). Assessing hand hygiene compliance among healthcare workers in six intensive care units. Journal of Preventive Medicine and Hygiene, 58(3), E231–E237.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5668933/

Nomides, N., Sweeney, J., Yee, M., Washer, L., Murphy, S., Valyko, A., & Sturm, L. (2017). Hand hygiene in the operating room: The final frontier. American Journal of Infection Control, 45(6), S102-S103.

https://doi.org/10.1016/j.ajic.2017.04.164

Pedersen, L., Elgin, K., Peace, B., Masroor, N., Doll, M., Sanogo, K., … & Bearman, G. (2017). Barriers, perceptions, and adherence: Hand hygiene in the operating room and endoscopy suite. American Journal of Infection Control, 45(6), 695-697. https://doi.org/10.1016/j.ajic.2017.01.003

Phan, H. T., Tran, H., Tran, H., Dinh, A., Ngo, H. T., Theorell-Haglow, J., & Gordon, C. J. (2018). An educational intervention to improve hand hygiene compliance in Vietnam. BMC Infectious Diseases, 18(1), 116.

https://doi.org/10.1186/s12879-018-3029-5

Price, L., MacDonald, J., Gozdzielewska, L., Howe, T., Flowers, P., Shepherd, L., … & Reilly, J. (2018). Interventions to improve healthcare workers’ hand hygiene compliance: A systematic review of systematic reviews. Infection Control & Hospital Epidemiology, 39(12), 1449-1456. DOI: 10.1017/ice.2018.262

Qasmi, S. A., Shah, S. M. M., Wakil, H. Y. I., & Pirzada, S. (2018). Guiding hand hygiene interventions among future healthcare workers: Implications of knowledge, attitudes, and social influences. American Journal of Infection Control, 46(9), 1026-1031.:https://doi.org/10.1016/j.ajic.2018.02.019

Quilab, M. T., Johnson, S., & Schadt, C. (2019). The effect of education on improving hand hygiene compliance among healthcare workers. Hos Pal Med Int Jnl, 3(2), 66-71. DOI: 10.15406/hpmij.2019.03.00153

Rodriguez, V., Giuffre, C., Villa, S., Almada, G., Prasopa-Plaizier, N., Gogna, M., Gibbons, L., García Elorrio, E., & Argentinian Group Hand Hygiene Improvement (2015). A multimodal intervention to improve hand hygiene in ICUs in Buenos Aires, Argentina: A stepped wedge trial. International Journal for Quality in Health care, 27(5), 405–411.

https://doi.org/10.1093/intqhc/mzv065

Saharman, Y. R., Aoulad Fares, D., El-Atmani, S., Sedono, R., Aditianingsih, D., Karuniawati, A., van Rosmalen, J., Verbrugh, H. A., & Severin, J. A. (2019). A multifaceted hand hygiene improvement program on the intensive care units of the National Referral Hospital of Indonesia in Jakarta. Antimicrobial Resistance and Infection Control, 8, 93. https://doi.org/10.1186/s13756-019-0540-4

Sands, M., & Aunger, R. (2020). Determinants of hand hygiene compliance among nurses in US hospitals: A formative research study. Plos One, 15(4).

https://doi.org/10.1371/journal.pone.0230573

Şen, S., & Kaya, H. (2018). A new teachıng strategy for hand hygıene complıance improvement in nurses. International Journal of Progressive Sciences and Technologies, 10(1), 111-119. http://ijpsat.es/index.php/ijpsat/article/view/555

Seo, H. J., Sohng, K. Y., Chang, S. O., Chaung, S. K., Won, J. S., & Choi, M. J. (2019). Interventions to improve hand hygiene compliance in emergency departments: A systematic review. Journal of Hospital Infection, 102(4), 394-406. https://doi.org/10.101h6/j.jhin.2019.03.013

Sopjani, I., Jahn, P., & Behrens, J. (2017). Training as an effective tool to increase the knowledge about hand hygiene actions: An evaluation study of training effectiveness in Kosovo. Medical Archives (Sarajevo, Bosnia and Herzegovina), 71(1), 16–19. https://doi.org/10.5455/medarh.2017.71.16-19

Tan Jr, A. K., & Jeffrey Olivo, B. S. (2015). Assessing healthcare associated infections and hand hygiene perceptions amongst healthcare professionals. International Journal of Caring Sciences, 8(1), 108.

https://search.proquest.com/openview/732fb9e01efe6af1fd192b29735f125a/1?pq-origsite=gscholar&cbl=1606338

Tartari, E., Fankhauser, C., Masson-Roy, S., Márquez-Villarreal, H., Moreno, I. F., Navas, M. L. R., … & Aelami, M. H. (2019). Train-the-Trainers in hand hygiene: A standardized approach to guide education in infection prevention and control. Antimicrobial Resistance & Infection Control, 8(1), 206.

https://doi.org/10.1186/s13756-019-0666-4

Teesing, G. R., Erasmus, V., Petrignani, M., Koopmans, M. P., de Graaf, M., Vos, M. C., … & Voeten, H. A. (2020). Improving hand hygiene compliance in nursing homes: Protocol for a cluster randomized controlled trial (HANDSOME Study). JMIR Research Protocols, 9(5), e17419. doi: 10.2196/17419

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. https://apps.who.int/iris/rest/bitstreams/52455/retrieve

Appendix A

Credible Sources

Author(s) (Formatted as in-text citation)	Database (CINAHL, EBSCO, Cochrane, Pro-Quest)	Peer-Reviewed (Yes/No)	Applicability (Yes/No)	Evidence Grade (Strength/ Hierarchy)	Appraisal (Brief summary of findings; how findings inform your project?)	Inclusion (Yes/No)
Musu et al., 2017	Cochrane	Yes	No	Level IV/Prospective study	Upon observing hand hygiene practices in two intensive care units, low levels of adherence to best hand hygiene practices were noted. Compliance rate ranged from 3% to 100% across implemented protocols. This study indicates that there is a gap in hand hygiene compliance that should be explored. My paper discusses how training and education can improve this healthcare problem.	No
Mageus et al., 2015	CINAHL	Yes	Yes	Level IV/Cohort study	The results from the observational study indicated an operating room compliance rate ranging from 3.1% to 15.1%. There was minimal compliance to hand hygiene and it was recommended that improvement strategies should include education and practical training. My research focuses on how education and training can improve hand hygiene compliance in the operating room.	Yes
Phan et al., 2018	PubMed	Yes	Yes	Level III/Quasi-experimental	Hand hygiene compliance after an educational intervention increased significantly. There were significant improvements in knowledge scores for healthcare professionals after the intervention. This study informs my project that education and training is an effective way of increasing hand hygiene compliance.	Yes
Quilab et al., 2019	CINAHL	Yes	Yes	Level IV/Cohort study	Upon the use of an educational study to improve hand hygiene compliance, there was a 20%, 15%, and 5% increase in compliance rate among physicians, nurses, and technologists respectively. This study supports my project on using education and training to improve hand hygiene compliance in the operating room.	Yes
Sands & Aunger, 2020	PubMed	Yes	Yes	Level IV/Cross-sectional	The cross-sectional study found out that hand hygiene compliance is dependent on hospital management communication, perceived performance, and increased interaction with patients. This study supports my project because education and training can help in improving the factors that cause poor hand hygiene practices.	Yes
Tartari et al., 2019	MEDLINE	Yes	Yes	Level III/Quasi-experimental	The Train-The-Trainers (TTT) intervention helped improve hand hygiene practices in several countries for over two years. My project uses the same approach of training healthcare workers in the OR on hand hygiene practices.	Yes
Saharman et al., 2019	MEDLINE	Yes	Yes	Level IV/Prospective study	Interventions that included education, feedback reminders, and role modeling improved hand hygiene knowledge score post-intervention. The compliance rate increased from 27% to 77% post-intervention. My study focuses on using education and training which are among the interventions that improved hand hygiene practices in the research.	No
Alshehari et al., 2018	Cochrane	Yes	Yes	Level I/Systematic review	The study identified the improvement of hand hygiene compliance through education, observation, education and training, reminders, and performance feedback. My project uses one of the above strategies, education and training, to improve hand hygiene compliance in the OR.	No
Graveto et al., 2018	CINAHL	Yes	Yes	Level I/Integrative review	The literature review indicates that training nurses help to improve hand hygiene compliance by 63% to 76%. The study supports my project that proposes the use of education and training to improve hand hygiene compliance. Positive results are expected from the project.	No
Ataiyero et al., 2019	PubMed	Yes	Yes	Level VII/Narrative review	Barriers to hand hygiene compliance include the infrastructural deficit, heavy workload, ignorance, and lack of reinforcement for the practice. This research identifies barriers that can be improved using education and training as proposed in my project.	No
Chhapola & Brar, 2015	EMBASE	Yes	Yes	Level III/Quasi-experimental	Nosocomial sepsis rate after an educational intervention for hand hygiene compliance decreased from 96 per 1000 patient-days to 47 per 1000 patient-days. There is a clear indication that educational practices can improve compliance to hand hygiene and my project uses the intervention to achieve positive outcomes in the operating room.	No
Mu et al., 2016	Cochrane	Yes	Yes	Level IV/ Observational prospective study	The use of a systemic multidimensional approach improved hand hygiene compliance from 37.78% to 75.90% over a 17-month period. My study focuses on training and education approaches that were among the interventions used in the above study to improve hand hygiene compliance.	No
Rodriguez et al., 2015	Cochrane	Yes	Yes	Level II/ Randomized controlled trial	The hand hygiene compliance rate was 66% in the control group compared to 75.6% in the intervention group. This study suggests that the use of interventions such as surveillance, education, training, and reminders can improve hand hygiene compliance. My project uses one of the above interventions and positive results can be expected.	Yes
Sopjani et al., 2017	EBSCO	Yes	Yes	Level III/Evaluation study	Training of healthcare workers improved hand hygiene compliance by 41.66%. The study supports my project which proposes the use of education and training to improve hand hygiene compliance in the OR.	No
Teesing et al., 2020	Cochrane	Yes	Yes	Level II/Randomized controlled trial	Hand hygiene practices improved from 35% to 50% in the intervention group. The role of education and training is strongly supported in this study to improve hand hygiene practices across many institutions.	No
Gould et al., 2017	CINAHL	Yes	Yes	Level I/Systematic review	The review identified interventions such as education for staff, increasing ABHR availability, performance feedback, and staff involvement to be useful in improving hand hygiene practices. My study uses education and training which is supported above to improve hand hygiene compliance among healthcare workers.	Yes
Sen & Kaya, 2018	PubMed	Yes	Yes	Level III/Quasi-experimental	Hand hygiene practices improved from 55% to 75% in the intervention group compared to 51% to 55% improvement in the control group. This study supports my project by demonstrating that training can be used to improve hand hygiene practices among nurses.	No
Nomides et al., 2017	Cochrane	Yes	No	Level VII/Quality improvement project	The study that focused on perioperative areas found that hand hygiene compliance can reduce HAIs. The study supports the improvement of hand hygiene compliance which is a priority in my project that proposes the use of education and training to achieve better outcomes.	No
Qasmi et al., 2018	Cochrane	Yes	Yes	Level IV/Cross-sectional	The study identified that institutions, where students had higher knowledge, demonstrated improved hand hygiene practices compared to those in private and semi-private institutions. The role of education and training is attributed to the observed differences in hand hygiene. This study supports my project by demonstrating that the level of education and training can affect and improve hand hygiene practices.	Yes
Chavali et al., 2015	PubMed	Yes	No	Level IV/Cross-sectional	The study which used a multimodal technique demonstrated an overall compliance rate of 78% compared to the baseline 63%. The study indicates that training healthcare professionals can improve hand hygiene practices. My study also uses education and training and positive results can be expected at the end.	No
WHO, 2009	WHO website	No	Yes	Level I/National practice guidelines	The WHO identifies gaps in hand hygiene compliance and presents different barriers to the best practice. Among the proposed solutions to hand hygiene compliance include education, training, observation, feedback mechanisms, and the use of reminders among many others. My study is supported by the WHO guidelines on the use of education and training to improve hand hygiene compliance.	No
Pedersen et al., 2017	MEDLINE	Yes	No	Level IV/Cross-sectional	Poor compliance with hand hygiene was associated with factors such as poor role modeling, inconvenience, and poor monitoring of hand hygiene practices. Self-awareness of hand hygiene was a challenge. My project uses the education approach to increase self-awareness on hand hygiene which will improve the compliance rate.	No
Hillier, 2020	Cochrane	Yes	Yes	Level VII/Expert Opinion	Hand hygiene remains the best approach to reduce HAIs. Compliance among healthcare workers especially this period of COVID-19 has demonstrated improved prevention of other diseases. Recommendations are made to include education practices in all healthcare institutions concerning hand hygiene compliance. These evidence-based guidelines support my project on the use of education and training to improve hand hygiene compliance in the operating room.	Yes
Ahmed et al., 2020	PubMed	Yes	Yes	Level IV/Cross-sectional study	The study found that only 65.56% of healthcare professionals were aware of the WHO guidelines on hand hygiene. Additionally, nearly half of the 212 participants had never attended a lecture on hand hygiene. This study supports my project on the need to educate and train nurses to improve hand hygiene compliance.	No
Butenko et al., 2017	EMBASE	Yes	Yes	Level I/Systematic Review	The review identified disparities between healthcare facilities and healthcare professionals on promotion and implementation of initiatives to improve hand hygiene compliance. Education and healthcare worker training can be an effective way of reducing the disparities.	No
Andriani & Nadjib, 2018	Cochrane	Yes	Yes	Level I/Systematic review	The findings indicated that compliance to hand hygiene reduced the rate of HAIs especially GI illnesses and respiratory diseases.However, most healthcare professionals lack enough education on hand hygiene. The findings and recommendations support my project of using training and education approaches to improve hand hygiene compliance.	Yes
Tan et al., 2015	Pro-Quest	Yes	Yes	Level IV/Descriptive study	Results showed that 27.6% of the respondents were aware of the impact of HAIs to the patients. Effective strategies identified to increase hand hygiene practices included education, training, and positive role modeling. My project uses the proposed approach of education and training to improve hand hygiene practices.
Seo et al., 2019	Cochrane	Yes	Yes	Level I/Systematic review	Only 50% of the reviewed studies reported more than 50% hand hygiene compliance. Strategies such as education, monitoring, campaigns, and providing feedback proved effective in improving hand hygiene compliance. This study gives support to my project that education and training can improve hand hygiene in the operating room.	No
Price et al., 2018	CINAHL	Yes	Yes	Level I/Systematic review	The study identified that both single and multimodal interventions were effective in improving hand hygiene practices. More emphasis should be put on targeting social influence, attitude, and self-efficacy. The results inform my project on the use of education and training to improve identified practices such as self-efficacy and attitude among healthcare workers.	Yes
Doronina et al., 2017	PubMed	Yes	Yes	Level I/Systematic review	The systematic review indicates that multimodal interventions and team leadership are effective in improving compliance. The use of education is also identified to be effective, but the results are short-lived. My project uses the educational approach to improve compliance to hand hygiene as supported by the systematic review.	No

OTHERS:

Graveto, J. M. G. D. N., Rebola, R. I. F., Fernandes, E. A., & Costa, P. J. D. S. (2018). Hand hygiene: Nurses’ adherence after training. Revista Brasileira de Enfermagem, 71(3), 1189-1193. http://dx.doi.org/10.1590/0034-7167-2017-0239

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