Hand Hygiene in the Operating Room to prevent healthcare-associated infections (HAIs)

Hand Hygiene in the Operating Room to prevent healthcare-associated infections (HAIs)
The rate of healthcare-associated infections (HAIs) has been on the rise and failure to observe preventive measures has led to increased morbidity and mortality among patients. Hand hygiene is recognized as the most basic precaution during the prevention of HAIs yet many healthcare providers fail to adhere to the practice. Both nurses and doctors especially those working in areas such as operating rooms, and critical care departments should practice high standards of hand hygiene to prevent the spread of microbes. Even though hand hygiene is very simple and straight forward, a lack of compliance between healthcare professionals is a problem. Both developed and developing countries face a challenge in ensuring compliance to hand hygiene with statics indicating an average of below 40% regarding hand hygiene compliance (Musu et al., 2017). As the healthcare sector moves towards delivering quality healthcare, there is a need to implement evidence-based practices to solve common problems such as compliance to hand hygiene among healthcare professionals.

Clinical/Organizational Problem

There is compelling evidence for low adherence to hand hygiene guidelines in many healthcare institutions. Although every department must observe hand hygiene in hospitals, the intensive care unit and operating rooms are always the top priority when implementing hand hygiene protocols. These departments handle patients who are at high risk of infection. These infections are one of the greatest challenges today because they cause unnecessary suffering, increase the cost of service delivery, and have a huge impact on morbidity and mortality. The main challenge in my facility is the compliance of hand hygiene protocol by nurses and surgical technicians in the operating room. Both the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) recommend washing hands to lower the risk of HAIs. The recommended practice is to wash hands with water and soap although other agents such as alcohol-based hand hygiene can be used.

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. For example, most healthcare professionals fail to do hand washing before touching the patient, after removing gloves, and before handling invasive devices for patient care. Additionally, the WHO recommends washing hands for 20 to 30 seconds but the practice is rarely adhered to (WHO, 2009). When assessing the availability of tools and equipment for hand washing, the operating room is well equipped with sinks that are visible and within proximity. Each station contains instructions for hand hygiene with alcohol-based formulations and the technique when using soap and water. According to my assessment, the staff lacks basic education on hand hygiene and there is little reinforcement of the practice in the unit.

Description of Problem

Hand hygiene is one of the most effective practices of infection control, but compliance is generally poor. The WHO explains that hands are the main pathways of germ transmission and hand hygiene is the most effective approach to prevent transmission (WHO, 2009). Because reinforcing this practice is difficult, the WHO provides indications for hand hygiene across all healthcare settings. First, it is recommended to wash hands with soap and water when visibly dirty or after using the toilet. Exposure to spore-forming pathogens, before handling medication, and after touching the patient are other indications for washing hands (WHO, 2009). In the operating room, hand hygiene is practiced by every healthcare personnel including moving from contaminated body surfaces to another body site within the same patient. These indications ensure that healthcare providers are aware of where and when to perform hand hygiene.

Compliance with hand hygiene protocols is important both to the healthcare providers and patients. Nurses and surgical technicians protect their health when they practice hand hygiene. Contamination with body fluids wound dressings and invasive devices put the healthcare provider at risk of acquiring infections. Hand hygiene ensures that the provider remains healthy which translates to long-term benefits to the patients and the organization. Studies demonstrate that healthcare providers clean their hands less than half the times they should (Musu et al., 2017). These providers are likely to infect patients and family members leading to an increased number of adverse events, and near misses. Compliance with hand hygiene also affects the organization in terms of quality care delivery because failure to perform the practice harms the patient. An increased rate of HAIs can have a negative impact on patient satisfaction which will affect financial reimbursement from the Medicare and Medicaid services.

Healthcare-associated infections represent the most frequent adverse event during care delivery. Infection prevention and control is the top-most solution to HAIs where hand hygiene is the basic approach. Patients and family members suffer greatly when infection prevention is not attained because it leads to prolonged hospitalization and additional costs for health systems. Annually, approximately two million Americans suffer from HAIs, and the direct cost of the infections to hospitals averages $45 (Mageus et al., 2015). There is an increasing rate of antibiotic-resistant microorganisms that increase morbidity and mortality rates among patients. Hand hygiene functions to prevent the spread of these deadly microbes that can be a burden to patients and the family upon infection. There is a need for change on hand hygiene practice in operating rooms to ensure attainment of patient safety, prevention of cross-infection and to reduce the costs associated with HAIs.

Explanation of Causes

Insufficient or very low compliance rates to hand hygiene have been reported worldwide with different factors leading to the practice. The WHO (2009) explains that baseline hand hygiene compliance rates range between 5% and 89% with an average of 38.7%. Observational studies conducted indicate that the 20 to 30 seconds time frame for hand washing is not strictly followed and healthcare providers are observed to take as low as 6 seconds to wash hands. To enable providers to solve the problem, the WHO provides a comprehensive list of barriers to effective hand hygiene. According to the report, observed risk factors for poor hand hygiene compliance include male gender, doctor status, working during the week, before contact with the patient environment, understaffing, and interruption in patient care activities (WHO, 2009). Additionally, most healthcare providers are observed to wash hands only when the duration of contact with the patient is long.

Compliance to hand hygiene in many units is a challenge because healthcare providers lack adequate knowledge on the importance of hand hygiene. Junior staffs are likely to copy from their superiors best practices like hand washing and when there is poor role modeling compliance with the practice is hindered. Some institutions may experience poor compliance due to a lack of basic equipment like soap, and a variety of sinks to perform handwashing. Research has established that a lack of active participation in hand hygiene promotion at the institutional level can hinder the practice. Nurse managers and other organizational leaders should organize internal awareness campaigns to instill the practice. Observational studies on hand hygiene compliance also indicate that the problem is caused by inconveniently located sinks, low risk of acquiring infections from patients, and ignorance or disagreement with the hand hygiene protocols. One key factor that is present in all studies is that lack of education on hand hygiene is a key barrier to motivation (Sands & Aunger, 2020). A powerful hand hygiene education program could greatly help in improving communication about the practice in the operating room and other hospital units.

Identification of Stakeholders

Preventing healthcare-associated infections is not an individual effort but rather a collaborative practice involving different members of the healthcare team. The key stakeholders for the project include the hospital administration, nurses, surgeons, and surgical technicians. These stakeholders are directly involved in the implementation of quality improvement processes in the department and help other staff members to maintain infection prevention practices. The team is also involved in policy formulation and execution of change when required. The four stakeholder teams will be responsible for ensuring the success of the proposed quality improvement project.

Healthcare administrators are responsible for ensuring quality is maintained and necessary changes are made to improve quality care. While the administrators have the role of monitoring organizational performance, they are responsible for bringing together healthcare teams to foster collaborative practice. The primary functions of the hospital administration will be approval of the project, communication of the new change to other stakeholders, and ensuring the quality improvement project is implemented successfully. The second team player involves the nurses working in the operating room including circulating nurses and the scrub nurses. These professionals work tirelessly moving up and down to provide essential supplies during surgery. The nursing team will be involved in implementing the new change and provision of feedback.

Infection prevention in the operating room also involves the surgeons and surgical technicians. The surgeons are present during every surgical procedure in the unit making them part of the team that should adhere to hand hygiene protocols. The surgical technicians are available to make sure tools for procedures are ready including the provision of necessary tools during procedures. Because these two teams work collaboratively in the operating room, their involvement in the project will be crucial to ensure hand hygiene is maintained in the department.

Discussion of Stakeholders

Hospital Administration

Quality improvement in healthcare organizations is a function of the hospital administration. The proposed change is a quality improvement process to increase compliance to hand hygiene in the operating room. The administrators have an interest in the project because it will help improve the quality of services delivered to patients while improving patient satisfaction. Additionally, successful implementation of the project will ensure HAIs in the unit decrease which will save financial costs related to prolonged hospitalization. The administration has the power to accept or decline the project and the long-term use of the new change will depend on policies set by the administrators. The administration influences the project because their decision and support will influence how other stakeholders respond to the proposed change.


The operating room consists of circulating and scrub nurses working together with other members during surgery. Nurses understand that hand hygiene is important during surgery to minimize the level of infection. Regarding the proposed change, the nursing team has the power to accept or decline the approach because it directly affects their culture. As the largest team of healthcare providers in the operating room, nurses have the power to change hand hygiene practices by leading through example. The interest of the nurses in the project lies in the patient satisfaction aspect that is likely to be achieved through practicing hand hygiene. The nursing team will be interested to know how the new change will decrease HAIs that will potentially increase patient safety. As the largest team in the unit, acceptance of the project will influence other stakeholders such as the surgeons towards accepting the proposed change.


Surgeons are part of the medical team that is required to maintain hand hygiene in the operating room. The surgeons interact with other members in the department including the patient and this leaves room for infection transmission. Hand hygiene is equally important to surgeons because they work to protect the health of the patients. The surgeons have the power to accept or decline the new project. This team has an interest in the project because the new change will help reduce the number of HAIs which will improve patient satisfaction. The team also has the interest to know how better they can prevent infection transmission in the operating to minimize adverse events. The surgeons can influence acceptance of the new change by the administrators, nurses, and other healthcare professionals including policies to sustain the proposed change.

Surgical Technicians

The surgical technicians provide assistance to set up a sterile operating room including assembling essential tools for surgery. As members of the surgical team, they have the power to accept or decline the new change. Their primary interest in the project is how the proposed change will increase patient and healthcare worker safety. Through their involvement in safe hand hygiene practices, the surgical technicians can influence how other healthcare team members will perceive the new change.

Explanation of Project

In a world where the evolution of technology is at the peak, the healthcare industry is seeing innumerable advances. However, most organizations have focused on the incorporation of technology into patient care and they have forgotten critical aspects such as patient safety and organizational performance. Quality improvement is meant to enhance safety, effectiveness, and efficiency. The current project on increasing compliance to hand hygiene in the operating room aims at assessing and improving the standards of quality care through the promotion of patient safety. It aims at engaging every member of the healthcare team in the operating room to improve hand hygiene practices which will translate to quality improvement in the facility.

The use of the evidence-based practice in improving quality is a current trend that has seen growth and expansion of the healthcare industry. These practices focus on the patient and they are observed to increase safety and patient-centered care during service delivery. The project utilizes current evidence on the improvement of compliance with hand hygiene practice in various healthcare settings. Upon implementation, the project will help increase patient and healthcare worker safety while reducing the number of healthcare-associated infections in the facility. This project also aims at enhancing and sharpening my research skills to achieve key competencies required for master’s prepared nurses. The project will demonstrate a synthesis of key professional competencies in areas of communication and building relationships, knowledge of the healthcare environment, leadership, collaboration, and organizational business administration.

Proposed Solution

Hand hygiene is the primary action for preventing HAIs and the spread of drug-resistant bacteria. These adverse outcomes are a burden in both developing and developed countries where up to 15% of admitted patients acquire HAIs (Sands & Aunger, 2020). Although hand hygiene is fundamental, maintenance and improvement of the practice are always difficult due to compliance issues. Therefore, reducing the rate of HAIs today calls for designing programs that can improve compliance with the hand hygiene protocols. The WHO provides comprehensive guidelines to hand hygiene and proposes the use of evidence-based practices such as training, the use of reminders, and the provision of hand hygiene supplies to improve compliance (WHO, 2009). The proposed solution involves the use of an educational intervention for staff in the operating room regarding hand hygiene practices and the importance of compliance with the practice.

The proposed educational program will involve the nurses, surgeons, and surgical technicians working in the operating room. 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. The content of the theoretical classes will be based on the WHO guidelines for hand hygiene together with institutional guidelines. The ‘Observation and Calculation Form’ designed by the WHO will be used to assess the baseline compliance rate before the implementation of the new change.

Evidence Summary

Hand Hygiene Practices in Operating Rooms

The operating room is one of the areas that require high standards of hand hygiene and sterility. Apart from the nurses and surgeons dealing directly with the patient, the anesthetists have an obligation of maintaining proper hand hygiene. This personnel handles the patient together with other equipment including drug preparations. Data from a few studies indicate that hand hygiene for these personnel ranges between 2-18% (Mageus et al., 2015). Moreover, there is evidence that operating room personnel are vectors for cross-transmission between equipment, supplies, the patient, and other healthcare providers. A study was conducted to explore and describe adherence to hand hygiene practices and opportunities for improvement in operating rooms. The results from the study are consistent with other literature that hand hygiene in the operating room is poor and providers only tend to wash hands after procedures (Mageus et al., 2015). It is recommended that strategies such as education and practical training should be used to improve hand hygiene practices during routine anesthetic care.

Compliance to Hand Hygiene Practices

Hand hygiene is the simplest and most effective way of preventing healthcare-associated infections yet compliance with the practice is low. Nurses have the most frequent patient care interactions and are at a greater opportunity to practice hand hygiene than other professionals. Preliminary data indicates that compliance to hand hygiene is far more associated with factors such as professional role and status, social affiliation, modification of the work environment, and social norms (Sands & Aunger, 2020). Therefore, strategies to improve compliance with hand hygiene should even focus more on individuals rather than using common approaches like observation and reminder systems. Educational approaches are critical because they touch the psychological aspects of healthcare providers and are more likely to influence behavior change. A survey conducted by Sands and Aunger (2020) concluded that education is a powerful effective intervention on hand hygiene and it helps at improving communication and openness.

Healthcare workers have an obligation to ensure patient safety during routine care of patients. To prevent transmitting infections, the WHO recommends the use of hand hygiene practice which is proven to prevent HAIs. However, there is a huge challenge in compliance with the hand hygiene guidelines among healthcare workers. Studies have proposed solutions to the problem including the use of education and training, posting hand hygiene reminders, and availing necessary supplies for practicing hand hygiene (Phan et al., 2018). Studies have also focused on critical areas that require high standards of hygiene such as operating rooms, neonatal intensive care units, and other ICUs.

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. 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. An observational study conducted in a healthcare facility in Florida involving 120 participants recorded a 20% increase in compliance among physicians and nurses (Quilab et al., 2019). From the results, it was concluded that education is an effective intervention in improving hand hygiene.


Education and Training to Improve Hand Hygiene

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). The WHO (2009) recommends education and training as primary approaches to improving hand hygiene practices in healthcare facilities. While training is recommended, the use of simulations in a practical bedside and hands-on approach greatly improves hand hygiene compliance. Engaging healthcare workers in practical training ensures that compliance rates increase and that the practice is maintained for a long period. Based on the WHO multimodal hand hygiene strategy, the Train-the-Trainers (TTT) initiative has shown increased knowledge on hand hygiene across many countries. Research to evaluate the effectiveness of the model indicates that it is effective in enhancing participant’s knowledge, sharing experiences, and networking. Using such educational approaches can increase compliance to hand hygiene in many institutions.

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.


Plan of Action

The first step towards the implementation of the project will involve seeking approval from the administration for the conduction of the study. The nurse educator will be approached to guide the process and help to clarify the need for the project in the institution. Approval of the project will lead to the conduction of a literature review and collection of the necessary material to present facts about the new change. The hospital research department will be contacted to provide baseline data on the rate of HAIs in the facility and the possible reasons why the current practice is not effective. The next step will involve the collection of data from the library concerning evidence-based practices for improving compliance to hand hygiene. The evidence will be used in the next step which will involve the introduction of the project to operating room staff and other stakeholders during the first meeting.

The second phase will involve the communication of the project to the operating room staff and other stakeholders. The hospital administration, the nurse educator, and the unit manager will help in communicating the proposed solution. A preliminary meeting will be held to explain to the stakeholders what is expected, their roles, and the duration of the study. The third phase of the project will involve educating operating room staff on hand hygiene using the WHO protocol and relevant evidence from the literature. The proposed approach will involve observation of hand hygiene compliance in the operating room and calculation of the observed rate using the WHO Observation and Calculation Form. Training of the providers will follow the observation period and emphasis will be put on indications for hand hygiene, ways that microorganisms are transmitted, duration of handwashing, and completeness of hand rubbing guided by the WHO checklist.

The last phase will involve practical education for hand hygiene practice and testing for understanding. Videos for hand hygiene in the operating room will be used and simulation exercises will be organized by the nurse educator to sharpen the skills of the staff. These activities will be reinforced by the use of posters regarding hand hygiene indications and application throughout the operating room. Upon completion of the training, observation of the new change will be done for one hour, twice a week, for six weeks. Meetings with the project implementation team to prepare reports will be done weekly including the administration briefing meeting to be done each Friday. Post-implementation discussions will be done at the end of the six weeks where the results will be compared with the baseline data to help in decision making regarding the proposed change.


A six weeks timeline will be enough to implement the proposed change in the operating room. The first week will involve seeking approval from the hospital administration, collection of evidence and education material, and communication of the project to the operating room staff. The preliminary meeting with stakeholders will also be done at the end of the first week. Week two of the project will involve observation to collect preliminary data about hand hygiene compliance in the operating room. The nurse educator will also organize simulation activities and training to be conducted in week three. The hospital administration will be contacted to provide the necessary resources for the training.

Week three of the project will involve theoretical training of staff about hand hygiene. Week four will involve practical training of staff about hand hygiene using online videos and simulation activities. The posters containing material on hand hygiene will also be laid in the operating room. Week five and six will involve reinforcement of the new change, selection of the monitoring team, and meeting with the project manager to give feedback on the initial preparations.

Required Resources and Personnel

Among the important resources for the project will be education and training material. The exercise will need access to the education hall, projectors for displaying content, tables for taking notes, and writing material for staff and the trainers. The simulation exercise will be done in the operating room after the completion of the procedures. The unit manager will help organize for distribution of extra soap and alcohol-based hand rub to be used during simulations and other training exercises. The nurse educator and unit manager will provide training during theoretical and practical sessions.

Proposed Change Theory

To guide and inform on the proposed solution, Kurt Lewin’s change management theory will be used. Lewin’s theory describes change management using three simple stages including unfreezing, change, and the refreezing stage. The unfreezing stage deals with the realization that change is needed in an organization. It involves dealing with emotions, impatience, and denial of the employees that change is required (Wojciechowski et al., 2016). Communication at this stage should be clear and employees should be involved to structure the change. The second stage involves the actual change where Lewin stresses the importance of taking quick steps to implement new change. Education, communication, and provision of support are essential to moving change. The third stage is the refreeze period that deals with solidifying the new change. Interim evaluations, monitoring, and making adjustments is required to sustain the change.

The proposed project will utilize the unfreezing stage by providing education about the importance of hand hygiene. Operating room staff will be engaged through meetings to ensure the change is well-anchored. Theoretical and practical training will represent the moving stage of Lewin’s theory. The nurse educator and the unit manager will help monitor the new change at every stage of implementation. Additionally, communication concerning the progress will be done weekly to keep employees and managers updated. During the refreezing, monitoring and making of necessary adjustments will be done. Making of policies and regular evaluation of the change will ensure adoption of the practice into the organization’s culture.

Barriers to Implementation

Barriers to change may result from systems issues within the institution, environmental factors, or resistance from individuals at all levels of the organization. The first potential obstacle is the failure to coordinate well with organizational leadership. The managers may be adamant about the new change considering the time and effort required to ensure the success of the proposed change. Secondly, employees may resist the new change because it does not involve new practices or approaches to hand hygiene. The most anticipated barrier is time especially for the training of employees given the busy nature of operating rooms. Staff working on a locum or double shifts including the busy surgeons might find it difficult to complete training.


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 Control4(1), 5. https://doi.org/10.1186/s13756-015-0042-y

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 Hygiene58(3), E231–E237. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5668933/

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 Diseases18(1), 116.


Quilab, M. T., Johnson, S., & Schadt, C. (2019). The effect of education on improving hand hygiene compliance among healthcare workers. Hos Pal Med Int Jnl3(2), 66-71. DOI: 10.15406/hpmij.2019.03.00153

Sands, M., & Aunger, R. (2020). Determinants of hand hygiene compliance among nurses in US hospitals: A formative research study. Plos One15(4).


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 Control8(1), 206.


Wojciechowski, E., Pearsall, T., Murphy, P., & French, E. (2016). A case review: Integrating Lewin’s theory with lean’s system approach for change. Online Journal of Issues in Nursing21(2). DOI: 10.3912/ojin.vol21no02man04

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.

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