Date of Graduation

Summer 8-9-2017

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Educational Leadership

First Advisor

Mary Seed

Second Advisor

Cathy Coleman


Prevention of hospital acquired infections (HAI) is a National Patient Safety Goal. Proper and frequent hand hygiene (HH) prevents HAI and various cross-infections in any setting. Audits of visual adherence for HH generates low compliance scores. During a yearlong improvement project, low monthly compliance scores of 52% in the Emergency Department (ED) of a community hospital, were reported by hospital auditors and found to be inaccurate by ED staff due to lack of visibility of HH actions because they occurred behind curtains or closed doors. Low scores and challenges were associated with behavioral change among ED team members, requiring multiple steps to achieve effective HH and enhancing visibility. Several evidenced-based interventions were implemented increasing HH rates. Increased compliance and visibility necessitated formal and informal education, environmental, and communication changes among team members. One major environmental intervention involved creating more HH/hand washing stations (HWS) in high traffic areas. Educational interventions included reinforcement of correctly utilizing alcohol-based hand-rub (ABHR), can be less irritating than handwashing. During implementation, mini dispensers of ABHR placed on badges or belts led to significant improvement and sustainable rates of HH compliance. Placement of ABHR and HWS were vital to optimize the HH protocol adherence and visibility. Current rates of HH behaviors have been sustained at 93% for 4 months. A CNL led improvement project in the ED resulted in sustainable outcomes by addressing educational and behavioral barriers for seasoned staff who were more resistant to change.