Good Adherence Involves More Than Just a Checklist

Infection Control TodayInfection Control Today, December 2021 (Vol. 25 No. 10)
Volume 25
Issue 10

Infection preventionists have been measuring hand hygiene with very little change in practice or retention of proper practice. Now is the time to think of new ways to improve hand hygiene and patient outcomes.

Health care–acquired infections (HAIs) result in increased patient care days, health care costs, and morbidity and mortality rates, and contaminated hands represent the most common mode of HAI transmission. It follows that hand hygiene is the most cost-efficient method to prevent the spread of infection. COVID-19 underscored this problem, according to data collected by the Centers for Disease Control and Prevention’s National Healthcare Safety Network (and as reported by Infection Control Today®).1

During the pandemic, patients were sicker and required more frequent and longer use of invasive equipment, such as catheters and ventilators. The data revealed increases in standardized infection rates, indicating that the increases were not simply a reflection of more devices being used.

Increasing staff hand hygiene is important for patient safety and health care reimbursement. Infection preventionists (IPs) have provided hand hygiene education in many methodologies to health care staff and have focused their efforts on staff handwashing practices. Practices in place to monitor hand hygiene among hospital staff include direct observation of staff and sensor badges that record hand hygiene practices, but little focus has been on nursing students’ hand hygiene practices or patient and visitor hand hygiene during hospitalization.

Although hand hygiene seems to be a simple practice, there is still low adherence in many health care institutions.2 Research aimed to increase adherence among health care workers can and should be applied to nursing students. Nursing students are introduced to hand hygiene in their fundamental nursing courses. Many schools utilize the practice of demonstrating hand hygiene, then require students to return the demonstration. If nursing students are expected to master the skill of hand hygiene and maintain adherence throughout practice, is a onetime return demonstration adequate to accomplish this objective?

Students are required to perform many competencies to complete clinical education in some facilities, but are they required to demonstrate a clinical skill, such as hand hygiene, that could save lives and decrease the cost of health care? Is hand hygiene consistently reinforced throughout the curriculum? Demonstrating hand hygiene in a skills lab does not ensure the correct technique will be employed in the clinical setting or will be retained throughout professional practice.

Is it monitored once students are in the clinical setting? Although it is a step in the process for both skills, would hand hygiene be more engrained if students were made to stop and think about the task of hand hygiene prior to performing skills?

Clinical Judgment

For years, we have determined students and health care staff to be competent in hand hygiene if they can provide a onetime return demonstration. A competency is the ability to use the knowledge and skills required to successfully perform critical tasks. Clinical judgment and reasoning involve reflection, which connects one’s own actions with outcomes. Integrating and synthesizing knowledge and skills in clinical settings is a component of nursing competency. Personal reflection on behavior is associated with competency improvement and is needed in professional practice. How do we, as IPs, design methodologies to include reflection into the measurement of competency?3

Students should be taught to think past hand hygiene as a simple skill. It must be reinforced as a necessary competency for patient safety. Hand hygiene must also be reinforced throughout the curriculum, not just taught as a skill in the fundamentals course. Could students have a sensor badge during their clinical rotation to measure handwashing practice after initial education and during their clinical rotation to show the students the reality of their practice? Would showing students actual data related to individual handwashing practices increase personal reflection on their practice? Would handwashing practices increase? Would patient safety outcomes improve?

The American Association of Colleges of Nursing (AACN) defines the curriculum content and expected competencies of graduates of accredited nursing programs in its Essentials document.4 Now is the opportune time to redesign the measurement of competency, as the AACN Essentials is recommending changes to nursing education. Nurse educators are developing new frameworks for undergraduate nursing education using a competency-based approach. The purpose of this competency-based approach to nursing education is to ensure high-quality nursing education and student outcomes to identify gaps in content identified as essential to safe practice.

Now is the time for nurse educators to focus on essential practices, such as hand hygiene. An increased focus on hand hygiene in nursing programs will serve to benefit the health care work force, the patient, and patient safety outcomes. Hand hygiene should be integrated into lab and simulation experiences as an objective required for successful completion of the activity. It must go beyond a checklist of completed or not completed. Students should be required to explain the rationale for hand hygiene. Just completing the task is not enough if we expect students to employ hand hygiene as part of their practice beyond the classroom and lab. Education must move away from passive clinical experiences if we are going to promote change and mastery in practice.5

Patients’ Hands

Patients have little opportunity to wash their hands unless the patient is ambulatory. While in the hospital, their ability to practice hand hygiene in the room is limited by accessibility to soap and water or to hand sanitizer because of mobility, cognitive issues, or limitations imposed by illness. Patient condition often necessitates reliance on the staff to assist with handwashing opportunities. Are health care workers and nursing students taught to offer patients an opportunity to wash or sanitize their hands throughout the hospitalization? Patients need to be offered the opportunity to sanitize or wash their hands after toileting, before meals, before touching incisions or wounds, as well as hospital equipment, before leaving their room, and upon returning to their room. Are we designing handwashing campaigns to include teaching staff and students to provide education on handwashing as well as opportunities for the patients to wash their hands?

Visitors are another source of HAIs. Until the pandemic, visitors were not provided the opportunity to wash hands. The opportunity for visitor handwashing should be offered upon entering and exiting the facility, touching elevators and hard surfaces in the health care facility, and when entering and exiting the patient room. Teaching health care workers and nursing students how to instruct visitors to wash hands will require a different skill set.

The World Health Organization designed the “5 Moments for Hand Hygiene” to increase adherence in a broad range of health care settings.5 This approach has also been adapted to other settings, such as vaccination campaigns, pediatrics, and ambulatory care settings.3 The most effective strategies utilize many modalities to reinforce learning. Strategies include posters, PowerPoint presentations, training videos, and brochures. It is also available in many languages.

A train-the-trainer model has been suggested as a means of disseminating knowledge while reinforcing best practices. Whether it is patients, visitors, or other health care colleagues, as students educate and train others, they will be reinforcing their own knowledge. This model can be implemented in school settings or for patient and visitor education in health care settings. However, training is only 1 element of implementation; there must be continuous evaluation and feedback provided to health care workers and students to ensure adherence is being achieved.6

Now Is the Time

IPs have been measuring hand hygiene with very little change in practice or retention of proper practice. Now is the time to think of new ways to improve hand hygiene and patient outcomes. Nursing education will be changing to prepare a graduate to meet the demands of the profession while maintaining patient safety. Now is the time to move away from our standardized checklist and embrace competency-based education of students and staff, which will maximize engagement and improve achievement of clinical objectives and patient safety outcomes. Although shifting to a competency-based educational approach will not be effortless, the potential increase in outcome achievement outweighs the labor to change our approach in the educational and health care facility. p

Mary Jean Ricci, MSN, RN-BC, is the director of clinical education and an assistant clinical professor at the College of Nursing and Health Professions at Drexel University in Philadelphia, Pennsylvania.

Mary Yost, PhD, RN, is an assistant clinical director of nursing and chairperson of the BSN Co-Op Nursing Program at the College of Nursing and Health Professions at Drexel University in Philadelphia, Pennsylvania.


Saunders H. How hospital administrators can help IPs manage HAIs. Infection Control Today®. October 15, 2021. Accessed October 22, 2021.

Lotfinejad N, Peters A, Tartari E, Fankhauser-Rodriguez C, Pires D, Pittet D. Hand hygiene in health care: 20 years of ongoing advances and perspectives. Lancet Infect Dis. 2021;21(8):e209-e221. Published correction appears in Lancet Infect Dis. 2021;21(10):e302.

Oh HS. Knowledge, perception, performance, and attitude regarding hand hygiene and related factors among infection control nurses in South Korea: a cross-sectional study. Am J Infect Control. 2019;47(3):258-263. doi:10.1016/j.ajic.2018.09.006

AACN essentials. American Association of Colleges of Nursing. Accessed October 23, 2021.

WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. World Health Organization. Accessed October 4, 2021.

McGaghie WC, Issenberg SB, Barsuk JH, Wayne DB. A critical review of simulation-based mastery learning with translational outcomes. Med Educ. 2014;48(4):375-385. doi:10.1111/medu.12391

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