Date of Graduation

Summer 8-15-2016

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions

First Advisor

Carole Santos



More than half of the staff nurses (65% through direct observation and 60% through interview) in the operating room (OR) department do not perform hand hygiene prior to insertion of an indwelling urinary catheter. This performance improvement project aims to educate all OR staff nurses on the practice of hand hygiene prior to the insertion of an indwelling urinary catheter by using the hand sanitizer included in the sterile catheter insertion kit. Two forms of interventions were provided in order to promote this process change. The first one being an education session with a power point presentation and the second was posting signage to multiple strategic areas. By December 31, 2016, 100% of the OR staff nurses are expected to be compliant with hand hygiene prior to catheter insertion. Staff evaluation conducted within the first week post intervention revealed promising results. Direct observation showed 80% of the staff nurses are utilizing the hand sanitizer provided in the kit. In addition, a survey used to evaluate the signage demonstrated that 72% of the staff agreed that the poster served as an effective reminder. Hand hygiene compliance should be audited on a quarterly basis. The audit results should be shared with the staff nurses and integrated into the next phase of the project to further enhance future review sessions and signage.