Critical Evaluation Of Hand Hygiene Procedures Homework 3 Answer

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Question :

Homework 3: Essay                      

Word limit: 3000 words +/- 10% 


A critical evaluation of an infection prevention and control practice, procedure, or policy

Critically examine an infection control practice , procedure or policy in your work area.

Synthesising your infection control knowledge, safety and cost effectiveness & where appropriate, the need to respect cultural values -   

Make recommendations to improve practice.  

Describe how you will implement and evaluate these changes and take appropriate action

Please note if you are currently not employed, answer this question in relation to your usual place of work/interest or your specialisation. The purpose of this is to develop your ability from novice.

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Answer :

Critical evaluation of hand hygiene procedures including moment 2 and moment 3


The act of washing hands with water and soap or rubbing hands with alcohol-based solution helps in minimising the spread of infection and kills the microorganisms to a very great extent this process is simply termed hand washing (Ejemot et al., 2020). This handwashing process is known as the best infection prevention and control method and is being used in healthcare facilities and daily lives for many decades. Also during the COVID-19 pandemic hand washing and rubbing with alcohol-based sanitiser have been the most effective approach for reducing the transmission of the rapidly spreading virus (Rundle et al., 2020). However, compliance with the standards prescribed for hand hygiene amongst healthcare professionals has not been internationally satisfying (Buković et al., 2021). The implication is a rising incidence of Healthcare-associated infections, which leads to a rise in mortality rates, morbidity rates, and healthcare costs in a world ravaged by preventable infectious diseases. For an already weak healthcare system, it furthermore demolishes every intention of improving patient safety. Hence, to improve hand hygiene and to improve handwashing compliance it is of major importance for the government to create and establish strategies that can help in minimizing hospital-associated infections. This in turn reduces hospital stays and mortality rates. One such initiative to meet the infection control and prevention standards is five moments of hand hygiene. The WHO Guidelines on Hand Hygiene in Healthcare Services outline the “Five Moments for Hand Hygiene”, which define the main moments where healthcare professionals must conduct hand hygiene to avoid infectious microbe transmission through the hands (Laskar et al., 2018). The principle specifies that before contacting and after patient contact, during aseptic or sterile treatments, after contacting the area of patients than after exposure to the body or bloody fluids, healthcare staff should practise hand hygiene (Laskar et al., 2018).

This assessment aims at highlighting the hand hygiene policy in Australia named "5 Moments for Hand Hygiene” in collaboration with the world health organization. Moreover, this assessment will only emphasize the moment 2 and moment 3 of hand hygiene for better evaluation and analysis. Also, it deals with the background, strategy (hand hygiene policy procedures), critical evaluation followed by recommendations for future practice. 

Background and context 

The main risk to patient care globally is healthcare-associated infections (HAIs) (Lakoh et al., 2020). HAIs are predominantly transmitted through the hands of healthcare workers, and HCW hand hygiene compliance is reportedly poor.  To develop successful hand hygiene improvement strategies, multidisciplinary actions are necessary. Healthcare workers' inability to comply with the requirements of hand hygiene puts workers and the patients' health at risk (Buković et al., 2021). Healthcare professionals who have direct contact with the infected clients are much more likely to take the microorganism out of the affected examination room with them and transfer it to other areas in their environment if they do not do hand hygiene either during, before or after leaving the room (Luo et al., 2020). Stethoscopes, portable electronics, writing utensils, and badges which are not only transferred to other patients' rooms and taken home with the person with his or her families may be among the surfaces affected. The lack of adequate handwashing procedures leads to hospital-acquired infections in vulnerable groups, including intensive and surgical care patients, which are avoidable. These hospital-acquired infections cause patients to undergo treatment longer, raising their risk of infection and susceptibility to other pathogenic organisms (Luo et al., 2020). The care for both the patients and the healthcare system becomes more difficult and expensive as the incidence of hospital-acquired infections grows.

In the chosen organization there have regular observation performed and it has been found that to comply with working rules of their own accord, existing hand hygiene practises depending on healthcare staff. Because of the lack of monitoring, non-compliance and inattentiveness are more likely. Nurses, in particular, have numerous chances for hand hygiene throughout a change that can go unnoticed if regular reinforcement and adequate training are not given. When employees are recruited, hand hygiene training is frequently provided and then not reconsidered until an issue occurs. Owing to a lack of support by leadership and management staff, as well as reduced front-of-mind knowledge, front-ended training sessions are unsuccessful as a key way of accomplishing full enforcement (Kurtz et al., 2017). 

The problem of hand hygiene non-compliance impacts many facets of the healthcare sector. Next, it leads to adverse patient effects. Patients acquiring hospital-acquired infections do not receive safe treatment from their medical team, resulting in additional costs, prolonged hospitalisation, and mistrust of the organisation, especially those in direct contact with the patient. Second, a healthcare professional's lack of hand hygiene puts them at risk of developing the disease. Decreased workplace protection, lost income from missing work time, the transmission of the disease to colleagues and personal connections, and likely hospitalisation are the effects of this (Le et al., 2019). Third, enforcement is also not sponsored by the corporate community. Hand hygiene has been identified as an obstacle to engaging in emergencies leading to a shortage of time to adequately perform the role, as well as poor leadership support (Le et al., 2019).


Intervention- The World Health Organization (WHO) has established a model called 'Five Moments for Hand Hygiene' in partnership with certain patient safety and infection control authorities to strengthen hand hygiene compliance and to provide a strong basis for understanding, training, monitoring and monitoring infection control practices (Wałaszek et al., 2019). This model emphasizes crucial times during routine aspects of care when hand hygiene is needed to prevent infectious organism transmission through the hands in hospital environments. This is a deviation from the conventional "two-moment" approach of hand hygiene, which stresses hand hygiene right before and right after patient treatment. The conventional view of hand hygiene is oversimplified, but it might not be as successful as the "five-moment" method in mitigating hospital-acquired infections when used. This is major because, during treatment, hands can become infected, allowing pathogens to be transferred from a colonised to a sterile specific location on the very same patient. Hand hygiene must be done "before touching a patient," "after touching a patient," "before any sterile or aseptic treatment," "after touching the patient's environment," and "after exposure to blood or body fluids," according to the "five moments" definition (Biswal et al., 2020). The "before" moments are recommended to prevent the possibility of transfer of contaminants to the patient and the same patient through one body location to a sterile site, whereas the "after" moments are meant to prevent the spread of infection to the healthcare worker, the hospital setting and other clients from the hospitals (Biswal et al., 2020). 

Stakeholders and engagement- The National Hand Hygiene Initiative (NHHI) was developed by the Australian Commission on Safety and Quality in Healthcare (ACSQH) as the portion of a sequence of interventions to prevent and minimise healthcare-associated infections in Australian hospital environments. The National Hand Hygiene Initiative (NHHI) is introduced by territories, states, and private medical associations and involves hand hygiene auditing, and also promotional and educational activities (ACSQH, 2019). The Commission offers an E-Learning system comprising online learning tutorials and the Hand Hygiene Compliance Framework for hand hygiene auditing applications to facilitate the introduction of the NHHI and enhance the progress of hand hygiene (ACSQH, 2019).

Implementation strategy- Moment 2 - before a procedure

According to the ACSQH hand hygiene policy followed by the chosen organization, the second moment is to wash hands before a procedure. As per this procedure, the hands should be washed immediately before initiating a procedure and no other thing in the near environment should be touched before starting the procedure. This helps in preventing the transfer of pathogens from the carer's hands to the already infected site or body of the patient ensuring their safety (ACSQH, 2019). The following phases have been marked by ACSQH to adhere with moment 2 (table 1)-

Hand washing before
Procedure example
Before inserting the needle into an invasive medical device/equipment or while giving injection on the skin of the patient 
Arterial blood gas, venepuncture, intravenous line flush, blood glucose level, intramuscular or subcutaneous injections 
While preparing a sterile field or administering or preparing medication via invasive means 
Nasogastric tube feeds, setting up the dressing trolley, intravenous medication and percutaneous endoscopic feeds
Administering the medication having direct contact in line with mucous membrane 
Suppository insertion, eye drop instillation and vaginal pessary 
The disruption or insertion of the circuit used for the administration of the invasive medical device 
The processes involve: tracheostomy, suctioning of airways, colostomy, invasive monitoring devices, PEG tubes, secretion aspiration, endotracheal tube, nasopharyngeal airways, urinary catheter, vascular access systems, wound drains and NGT 
Any test, procedure, or patient care that includes mucous membranes or non-intact skin 
Burns dressing, digital rectal examination, digital examination/assessment of new-born palate, wound dressing, surgical procedure and gynaecological procedures and invasive obstetric (ACSQH, 2019)

Moment 3 - after a body fluid exposure risk or procedure 

Hand hygiene instantly following a procedure or risk of exposure to body fluid as hands might be infected with bodily fluids. Even though the healthcare professional has gloves on hands, upon withdrawing them, hand hygiene will still be carried out as gloves are often not a maximum impenetrable barrier. The hands to take off the gloves may also be dirty. This procedure is helpful to defend against the exposure of possible pathogens by healthcare workers and the healthcare community (ACSQH, 2019).

After moment 2

Following any possible exposure to bodily fluids
Contact with already utilized specimen pathology samples/jars, contact with already utilized urinary bedpan/bottle, after touching the outside of a drain, indirect or direct contact with sputum through tissue or cup, cleaning urine, cleaning dentures, faeces, or vomit spills from the patient's environment

Contact with: saliva, semen, wax, colostrum, faeces, pleural fluid, ascites fluid, blood, mucous, tears, breast milk, urine, vomitus, cerebrospinal fluid and organic body samples such as cells samples bile, bone marrow or biopsy samples (ACSQH, 2019).  


Compliance in respect of prior and after patient care operation has been defined clearly and widely in many studies on hygiene practices in healthcare environments. This procedure falls short of identifying the most common and essential hand hygiene signals during the care series. Lack of time is another major obstacle in hand hygiene policy (Madden et al., 2019). The majority of the clinical procedures needs rapid actin and quick involvement from the healthcare professional hence leaving very less time for performing such lengthy procedures of 5-time hand washing (Alegbeleye, 2020). In support of this, a study conducted by Løyland et al. (2020) outlined that WHO's "5 critical moments of hand hygiene" is well accepted by nurses and many other carers but the barriers include time constraint, lack of team engagement such as support from physicians, enough resources for 5 times of hand hygiene, forgetfulness and emergency situations. In order to improve nurse compliance, the researchers developed a number of improvements in practise, including professional support, cultural improvements, and availability of resources.


The study by Stahmeyer et al. (2017) shows that the second and third moment of hand hygiene defined by the WHO are the crucial moments as these are the phases with most surface contacts in line with patent contact. These moments can save the virus from getting transmitting to many surfaces like injection devices, invasive devices and dressing tools which are the common surfaces of microbe transfer. Next, Sundal et al. (2017) identify that moments 2 followed by moment 3 during patient are not always followed as the ac of time stands the barriers and does not allow the healthcare provider to waste time on such processes. Though it has positive outcomes but is not well accepted in many healthcare facilities. Although, research suggests that healthcare professionals follow hand hygiene before and after the patient contact but fails to do it during the procedures (Hillier, 2020). Such that the adherence to moment 2 and moment 3 is still not satisfactory and need further analysis and modifications. Biswal et al. (2020) contend that the overall ratio of healthcare professionals including doctors and nurses, the rate of complicating was during moment 3 that exposure to body fluids accounting for 67% and was lowest before moment 2 that is only 4%. 

Alshehari et al. (2018) conducted a study on hand hygiene compliance. The purpose of this study was to demonstrate to nurses, doctors, and managers that their hand hygiene procedures influence their patients' health outcomes. In designing practise modifications for hand hygiene, the collaboration between practitioners and researchers provided the best results. The researchers were able to strengthen hand hygiene enforcement in an operating room environment by establishing safe environments, participating in cross-disciplinary communication, and introducing practise improvements (Alshehari et al., 2018). Hence, implementing the new "5 moments of hand hygiene" procedure should also be performed with collaboration between the healthcare team. Next study aimed to make proper hand hygiene a routine and a component of the critical care unit's environment. Researchers found that the introduction of a new hand hygiene procedure with support from nurses on the system has been found to be successful in many research reports (Sands et al., 2020). To uncover challenges to hand washing in daily personal and professional life, the researchers circulated a questionnaire and interacted with nurses from the organization. For the means of conducting pre-shift hand hygiene, researchers used the findings of these studies to introduce a strong procedure for modifying shifts and introduce a special washroom (Sands et al., 2020). In the current organization also the nurses should be chosen as the major instructors and learners for the moments of hand hygiene. 

The use of multiple components to assess hand hygiene enforcement among healthcare workers was the objective of the study undertaken by (Musu et al., 2017). To assess enforcement rates, the author explores the benefits and drawbacks of using direct observers, digital dispenser monitors, digital compliance monitoring equipment, and camera-based technologies. The author agrees that direct observations are most useful at the moment because they can offer direct input and instruction, but their participation is deterred from their use as indicators of compliance data by the Hawthorne effect and the smaller sample size. He promotes the use of electronic surveillance systems in collaboration with direct monitors to get a clearer overview of healthcare workers' actual clinical practices.

Recommendations to improve practice 

Education and training- Hand hygiene enforcement rates grow as a result of improved education and the introduction of hand hygiene activities into the occupational area. Hand hygiene performance in an orthopaedic operating room unit improved after inters professional groups heard about avoiding patient acquired infections in the care unit (Alshehari et al., 2018). In an intensive care unit, developing a culture of washing hands via action-oriented training improved handwashing compliance. Hand hygiene enforcement amongst Australian nurses in 49 hospitals improved as a result of education and awareness about the benefits of hand hygiene (Alshehari et al., 2018). More research is required into the effects of work environments and personal motivating factors on hand hygiene practices. 

Implementing Practice Change- Nurse Instructors, floor managers, and nurse managers must all be on board in order to make long-term improvements in hand hygiene practices. For the goal of informing nurses on hand washing as it relates to health and patient safety, reducing healthcare associated infections, and reducing cross-contamination, teaching assistants are required. Once floor nurses have been trained, they can incorporate what they've learned in their daily work. These nurses will also positive role models for the remainder of their unit when it comes to effective hand hygiene (Kilpatrick et al., 2019). Encouragement for adopters of these modifications from nurse managers is also important. Nurse Managers should resolve concerns related to their employees' lack of resources, improvements in policy and procedure, staffing, and adherence to education.

Proper funding- Next, any materials that are presently inaccessible should have funding secured. If additional hand washing facilities are necessary, funding must be obtained before any improvements to the protocol can be introduced. Second, it is important to build a strategy that includes nurse administrators, registered nurses and floor nurses. The transition would go more efficiently and can be more easily recognized if everyone is engaged in the development and design process (Gupta et al., 2019). It is important for progress to allow feedback and recommendations from healthcare staff whose daily practise will be modified.

Audits- Daily evaluations must be undertaken in order to assess progress after introducing hand washing training and cultural improvements. Before making any improvements, a baseline audit of hand hygiene practices must be done. Audits must also be carried out after improvements in culture and education are in effect for a period of one month, 3 months, 6 months, and one year in order to assess the success of the reform in practice and determine if more training and developments are necessary (Kilpatrick et al., 2019).  Increased rates of hand washing enforcement for all healthcare professionals at the monthly audits, which are maintained over the one-year audit, will be an improvement.


From the above assessment, it can be concluded that the initiative used by WHO in association with different national, state and country-level authorities is a good initiative challenging the conventional initiatives in terms of safety and better health outcomes. The organizations are complying with these moments of hand hygiene and are implementing change in culture. Second and third moment of hand hygiene defined by the WHO are the crucial moments as these are the phases with most surface contacts in line with patent contact. Moment three have high compliance rates up to 67% but moment 2 compliance needs further analysis and training for better health outcomes for both patients and healthcare workers. Although there are many barriers to achieve these goals to the maximum level. These barriers include time constraint, lack of team engagement such as support from physicians, enough resources for 5 times of hand hygiene, forgetfulness and emergency situations. To overcome these barriers actions such as education and training, implementing practice change, proper funding and on-time audits can be helpful.