Date of Graduation

Spring 5-19-2017

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions



The aim of my CNL Internship Project is to decrease the incidence of healthcare acquired C diff infections at the acute care unit 1800 to zero for the next quarter. This will be accomplished by developing an action plan to address the issue by collecting data from audits and developing evidence based practice interventions. The process begins with patient’s admission to the medical surgical unit and ends with patient’s discharge from the medical surgical unit.

By working on the process, the Hospital Acquired Infection (HAI) team expects to improve infection control among all units, increase patient safety, reduce unnecessary costs and patient’s length of stay, and reduce risks of mortality and morbidity.

The alarming findings the month of January 2017 have reported 5 different cases of C diff in different departments in the hospital, audits on hand hygiene and PPE compliance results reveal lack of knowledge of proper techniques. The goal is to have a clinical nurse leader assigned to each department in the hospital to implement the project at the center of the microsystem and to promote quality outcome. A HAI workgroup will meet every two weeks to discuss interventions and outcomes. According to the AACN (2007), “ CNL applies the nursing process at the point of care through the strategic assessment, diagnosis, intervention, and evaluation of the unit as a whole to guide efforts for systematic, quality, and safety improvements.”

Materials used in the project are hand washing standard work and PPE doffing and donning posters that are currently displayed by all the patient’s doors on all units. In addition, the quality nursing boards are updated with information of the progress of the work of infection prevention of the HAI workgroup. Moreover, management and leaders are re-enforcing the 20 seconds hand washing techniques and proper donning and doffing of PPE during huddles. Real time education simulation and observation of hand washing took place in some of the units to re-educate staff and ensure compliance. Audits are no longer performed on paper, the organization has adopted and online tool Tracers with AMP (Accredited Manager Plus) product for data collection through the Joint Commission Resources this will allow users to record, track, evaluate and analyze data collected.


American Association of Colleges of Nursing (AACN). (2007). White paper on the

education and role of the Clinical Nurse Leader. Washington, DC: Author.

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