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IMPLEMENTATION PROJECTS

Increasing patient participation in hand hygiene practices in adult surgical wards in a tertiary institution: a best practice implementation project

Choong, Tze Lin BScN (Hons), RN1; Lim, Zhao Jun BScN (Hons), RN1; Ho, Alexander Guan Ting BScN (Hons), RN1; Goh, Mien Li PhD, MHlthSc (Edun)1,2

Author Information
JBI Evidence Implementation: March 2022 - Volume 20 - Issue 1 - p 53-62
doi: 10.1097/XEB.0000000000000290
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What is known about the topic?

  • Inpatients are at risk of hospital-acquired infections.
  • Hand hygiene practices reduce risk of hospital-acquired infections.
  • Contaminated hands are a common mode of transmission for hospital-acquired infections.

What does this article add?

  • Involvement of patient participation in hand hygiene is essential to improve patient's well being.
  • Implementation strategies based on best practice recommendations and audit criteria developed by JBI improve staff compliance on promoting hand hygiene participation among patients.
  • The evidence-based practice project demonstrates that sufficient patient--family education pamphlets on hand hygiene and nurses’ regular reminders improve patients’ participation in hand hygiene practices.

Background

Hand hygiene is intended to reduce the risk of pathogen transfer using methods such as alcohol-based hand gel, or soap and water.1 Hand hygiene is often an important and effective infection control measure to reduce the risk of transmitting microorganisms associated with hospital-acquired infection (HAI).2 HAI is a major problem faced by all hospitals worldwide as it increases a patient's length of hospitalization stay, cost of hospitalization bills and is costly to the healthcare system.3 As such, hospitals have placed great emphasis on hand hygiene as one of the important components in infection control.4

Transmission of HAI often occurs through direct contact, such as contaminated hands of healthcare professionals and other environmental sources.5 Therefore, preventing the spread of HAI requires performing proper hand hygiene at key moments during patient care.6 Most studies in the literature emphasize the need to improve hand hygiene practices and the compliance of healthcare professionals to perform hand hygiene in order to prevent the spread of HAI.5 However, there is also a likelihood that patients may also be involved in the transmission of pathogens.7 Monitoring a patient's adherence to hand hygiene practices is equally important and could aid in the reduction of HAI.8 Throughout a patient's stay in the hospital, they not only interact with healthcare professionals but also with visitors, porters and other patients who could also be carriers of HAI.9 Therefore, improving a patient's hand hygiene practices through patient involvement may reduce the risk of HAI and should be considered as a main area of concern.

Patient involvement is defined as the active participation of patients in different aspects of their health and everyday care, and has been progressively identified as a key component in redesigning healthcare processes.10,11 It improves patient's motivation, compliance, satisfaction and involvement in decision-making.12 An evidence-based quality improvement project conducted in a Singapore hospital suggested that improving a patient's knowledge of hand hygiene re-establishes autonomy and ownership of one's health, hence contributing to improved patient hand hygiene practices and patient safety.9 Other studies have also attempted to integrate patients’ involvement in improving hand hygiene compliance in the healthcare setting by encouraging patients to request healthcare professionals to perform hand hygiene prior to any patient care activity.13,14

Although the role of patients in hand hygiene as a means to prevent the transmission of pathogens has been widely recommended, it still remains an underused method of preventing HAI. An integrated review, which investigated the perceptions of patients and healthcare professionals on patients’ involvement in hand hygiene compliance concluded that patients still had reservations in requesting healthcare professionals to perform hand hygiene.15 Furthermore, some healthcare workers also felt uncomfortable and stressed out when prompted by patients to perform hand hygiene. Common barriers to patient involvement include, but are not limited to, patient's poor knowledge on hand hygiene, environmental issues, such as healthcare institutional prompts or accessibility of alcohol dispensers, cultural factors and the patient--nurse relationship.16–18

Clinical issues

Staff anecdotally reported that patients on surgical wards were not performing routine hand hygiene, although it was thought that staff were providing the patient hand hygiene educational pamphlet as expected. Through informal observation, it also became clear that ward staff were not routinely reminding patients about the risks of infection, and the benefits of hand hygiene during their admission. A direct observation conducted on 53 adult inpatients in three surgical wards revealed that 98% of the patients received an educational pamphlet on the importance of hand hygiene to prevent the spread of Methicillin-resistant Staphylococcus aureus (MRSA). However, only about 52% of the patients reported that they performed hand hygiene in the ward. Lastly, we observed that hand hygiene was performed by 49% of the patients after toileting, and by 11% of the patients before having meals. These observations have implications on both patients and nurses. Patients are at risk of HAI despite hand hygiene compliance by healthcare professionals. Nurses spend most of their time providing bedside care 9 and are in a favorable position to influence a patient's behavior and self-efficacy with hand hygiene practices, and encourage them to adopt a habit of performing hand hygiene during their stay in the hospital.

Aims and objectives

The aim of this project was to improve patients’ hand hygiene practices and assess patients’ compliance with hand hygiene practices in the general surgical wards of a tertiary hospital. The specific objectives were:

  • (1) To ensure that there was 100% compliance of staff performing hand hygiene education within 48 h of patient admission using a standardized hospital-approved patient--family education (PFE) pamphlet.
  • (2) To ensure patient compliance with hand hygiene before meals and after toileting is at least 80%.

Methods

The evidence-based implementation project was conducted in three phases using the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) audit and feedback program. The first phase of the project involved forming a team of nurses to conduct a baseline audit using evidence-based quality indicators. The second phase focused on assessing the preaudit data to identify potential problems. Subsequently, the team used the GRiP framework to recognize the barriers that contributed to a problem and developed various strategies, which could be implemented. Finally, the last phase involved conducting a postimplementation audit to evaluate the results of the strategies and identify further gaps that should be included in future audits. The entire project was conducted in three phases within a period of 6 months, from February to December 2018. A Gantt chart was used to guide the team's activities.

Evidence-based recommendation

The JBI Evidence Summary mentioned that ward nurses need to educate patients to improve the level of personal hygiene, which include hand hygiene practices. Hand hygiene practices should be directed to both healthcare workers and patients, nurses must be encouraged to remind patients to perform hand hygiene practices and assist them whenever required.19,20 Nurses may encourage patients to perform hand hygiene practices using soap and water when hands are visibly dirty, or using an alcohol-based hand rub.20 Then patients must ensure that the surface area on both hands are washed. They should wet their hands, apply soap and vigorously rub their hands together, and thereafter dry using a single-use towel.20 Patients using an alcohol-based solution must ensure all surface area on their hands are rubbed with alcohol-based solution until dry.20

Sample and setting

The project was conducted in three inpatient adult surgical wards in a tertiary institution and major referral centre, which provide a comprehensive range of specialist care for adults, women and children. This hospital has more than 1100 beds in inpatient wards. Convenience sampling method was used to obtain the sample. The sample size calculation was done according to the recommendation from the Joint Commission International; a sample of 30 patients was adequate when the total number of patients in each ward was between 30 and 100.21 The inclusion criteria to participate in the project were adult patients who were: alert and conscious, able to ambulate independently or with assistance (e.g. using a wheelchair), and bedbound. The patients that are bedbound are confined to their bed, and unable to access soap and water to wash their hands. They are at risk from contaminated hands of healthcare professionals and other environmental sources, such as bed rails.5 Hence they would require assistance from nurses or caregivers. The exclusion criteria were patients who: were unable to follow instructions, had altered mental status, and were unconscious.

Phase 1: stakeholder engagement (or team establishment) and the baseline audit

The project team consisted of three nursing leaders and three registered nurses from three participating wards. A registered nurse in charge of infection control was also recruited in each participating ward. This project was mentored by a senior nurse educator from the Evidence-Based Nursing Unit of the institution. The project leader was in charge of managing the project, initiating regular meeting sessions with the team members and providing guidance in the event of any difficulties or doubts. The mentor was responsible for supervising the project and developing the audit tool. The ward nurses and nursing leaders were responsible for implementing the project, providing feedback and collecting data.

The stakeholders of this project were the ward staff nurses, enrolled nurses, nursing leaders -- this included nurse managers, nurse clinicians and nurse educators, basic care assistants and patients from the three wards. The project was endorsed by the assistant nursing directors. The nursing leaders played an important role in supporting the change, recognizing the need to improve the patients’ hand hygiene practices, promoting an evidence-based culture in the ward, ensuring the smooth progress of the project and communicating the implementation of the evidence-based practice to the ward staff.

The nurse leaders supported the project aim, allocating time and resources to implement the project. The nurse leaders facilitated the processes of the projects in the ward, such as planning the staff roster to ensure the project team are able to organize meetings and the GRiP session with ward staff. During the implementation phase, the nurse leaders ensured that the strategies to improve the best practice were implemented as planned, such as overseeing the ward clerk or the infection control liaison nurse (ICLN) have the MRSA PIL readily available at the cabinets. The nursing leaders ensured the project team is able to effectively communicate their project plan and implementation strategies to the ward staff by uploading the information to the electronic nursing platform and reminded nurses during roll call. The nurse leaders’ active involvement and engagement with the project team together facilitated the ward staff acceptance to participate in the project.

JBI-PACES was used to generate the audit criteria for the preimplementation and postimplementation phases. The data were collected on a data collection sheet developed using the audit criterion presented in Table 1. The criterion is considered fulfilled when the following four observations and validation documentation from the nurses have been met.

Table 1 - Data collection sheet
Patient demographics JBI criterion Observation Validate documentation Met Not met Remarks
Date of audit:Patient's initial:Ward:Gender:Female/maleAge:LOS:Mobility:□ Ambulatory□ NonambulatoryDiscipline: Patients have received education regarding hand hygiene 1. Have you received this leaflet? (show sample of PIL) • Yes/• No2. Do you think hand hygiene is important/effective in reducing harmful infections? • Yes/• No3. Do you (patient) practice hand hygiene? • Yes/• No4. When do you practice hand hygiene?Before eating • Yes/• NoAfter going to the toilet • Yes/• NoAfter using bedpan/urinal • Yes/• No/• NA□ Others: ________________ □ Check completion of patient and family education assessment(Teach/Reinforce or Met within 48 h of admission/transfer to ward)□ Check patient received correct language of the MRSA Patient Information Leaflet
JBI, Joanna Briggs Institute; LOS, length of stay.

Observation 1: patients had to verbalize that they have received a copy of the MRSA patient information leaflet (PIL) and they were literate in the language used in the leaflet. The criterion was fulfilled when the patient received the PIL and was given a PIL in a language they understood.

Observation 2: patients had to verbalize that they understood the importance of hand hygiene in reducing harmful infections in the hospital. This criterion was fulfilled when they verbalized that performing hand hygiene was able to reduce harmful infections in the hospital.

Observation 3: Patients had to verbalize that they performed hand hygiene during their stay in the hospital. This criterion was fulfilled when patients verbalized that they performed any form of hand hygiene during their stay.

Observation 4: patients had to verbalize that they performed hand hygiene when opportunities arise, such as before meals, and after toileting or using the urinal. This criterion was fulfilled when patients performed hand hygiene whenever an opportunity arose.

The audit criterion is considered not fulfilled where either the patient, or the documentation did not report or record the best practice recommendations that had been delivered.

Three registered nurses were involved in the baseline audit, which was conducted in March 2018. The audit took a period of 2 weeks. It involved interviewing patients who met the inclusion criteria and going through patients’ medical records to ensure that the completion of patient education on hand hygiene had been documented by ward nurses. The collected data were documented in the data collection sheet and entered into the JBI-PACES program.

Phase 2: design and implementation of strategies to improve practice using the Getting Research into Practice framework

The preimplementation audit results were presented to the ward nurses during roll call every afternoon over a period of 1 week. The team also sent the results to the nurse managers of the participating wards via e-mail. Nurses who attended the roll call were asked to sign a communication list to indicate that they have received the information.

The team utilized the GRiP model to identify the barriers and gaps related to the low adherence to hand hygiene practices among patients. Sharing sessions were conducted to allow ward nurses to share and voice their opinions with the team members in a safe environment. The problems, barriers and the respective strategies were developed based on the contributions of the team and the ground nurses.

Phase 3: follow-up audit postimplementation of change strategy

After the implementation of strategies and continuous reinforcement by the team members, an audit was performed in July 2018, 3 months after implementation. The postimplementation audit was carried out over a period of 4 weeks, using the same audit tool utilized in the preimplementation audit on 94 patients. The results of the postimplementation audit were shared with key stakeholders, which included the ground nurses and nursing leaders.

This project did not require ethics approval as it aimed to improve the quality of clinical practices within the clinical setting. Nonetheless, approval to conduct this evidence-based implementation was granted by the nursing leaders and administrators of the hospital. During the audits, the project team members did not collect any patient's name and identification number.

Data collected during the audits were analyzed using the SPSS version 26.0 software (IBM Corp., Armonk, New York, USA). The Fisher's exact test was used to analyze categorical variables between the baseline and postimplementation audits. The results were statistically significant when P was less than 0.05.

Results

Phase 1: baseline audit

The preimplementation audit (N = 94) revealed that 19.1% of patients fulfilled the JBI criterion for patients who had received hand hygiene education within 48 h of their ward admission or ward transfer (see Fig. 1). The auditors interviewed 42 female patients and 52 male patients, of which 93 were ambulatory patients and 1 patient was considered nonambulatory. Patient mobility was classified as either ambulatory or nonambulatory. Ambulatory patients included those who were mobile wheelchair users, walking with assistive devices, such as a walking stick or walking frame, and ability to walk independently. Patients who were on absolute bed rest were considered nonambulatory. The average length of stay for patients included in this study was 6.7 days. A breakdown of the observations showed that 64.9% of patients received education on the importance of hand hygiene. More than 90% of patients recognized that hand hygiene is important and reduces harmful infection during their hospitalization. However, only 48.9% of patients practiced hand hygiene before eating and 33% of patients performed hand washing or hand rubbing after using elimination aids, such as a bedside commode, bedpan, urinal and diapers. In order to fulfil the criterion, a nurse who performs hand hygiene education has to document it in electronic nursing documentation, an electronic medical records system, to indicate whether a patient has fully met and understood the hand hygiene education provided by the nurses or requires reinforcement on the importance of performing hand hygiene in the ward. Reassessment and evaluation of hand hygiene education provided to patients were reviewed every 3 days.

F1
Figure 1:
Compliance with the best practice for the audit criterion in the baseline audit (%) of patients received education regarding hand hygiene (N = 94).

Phase 2: strategies for Getting Research into Practice

Nurses from the three wards participated in the GRIP session with the project team. The team utilized the GRiP model and identified that there were insufficient information leaflets, hence was not able to provide or facilitate effective patient education. Another problem was patients do not practice hand hygiene at the right moments. The strategies identified were to ensure sufficient educational resources available in the ward, and to use the teach-back method to educate patients. Another strategy identified was to design a regular reminder to patients to perform hand hygiene practices.

On the basis of barriers identified, strategies were targeted to overcome the barriers to improve adherence to hand hygiene practices among patients as shown in Table 2. The 3-month implementation occurred from April to June 2018. The strategies included the following:

Table 2 - Getting Research into Practice matrix
Barriers Strategies Resources Outcome
Insufficient PIL availableIncorrect language of PIL provided to patient Ward clerk/infection control liaison nurse (ICLN) to ensure adequate supply, to procure MRSA patient information leaflet (PIL) monthly of each language (Chinese, English, Malay and Tamil)ICLN and Team members to ensure MRSA PIL are organized and sufficient MRSA PIL filing cabinetsLabelling MRSA PIL are readily availablePatient receives correct language PILPatient understands the importance of hand hygiene practices
Ineffective teaching method for patient education Encourage nurses to use teach-back method during patient education Communication list
Patients feel that their hand is not visibly soiled and hence feel there is no need to perform hand hygieneAlcohol-based hand rub is inaccessible to patients because of their limited mobility, and so forth Nurses:regularly remind patients to perform hand hygiene at the right momentsinform patients that alcohol-based hand rub is readily availableencourage/assist patients to perform hand hygiene at appropriate opportunities, such as: Before and after meals After toileting needscheck whether patients have performed hand hygiene in the previous shift during shift handover Hand hygiene postersHand rub/hand washing Increase patient's hand hygiene practice

Ensuring sufficient MRSA pamphlets in wards to allow nurses to conduct patient and family education upon admission to the ward and distributing pamphlets in the language that each patient could read and understand.

Delivering interactive educational sessions during afternoon roll call to educate nurses on how to notify hand hygiene-appropriate occurrences to patients as stated in the pamphlet and encouraging them to use the teach-back method when conducting patient education.

During physical check of patients before the start of the afternoon shift, nurses had to regularly remind patients to perform hand hygiene at the right moments, such as before eating and after toileting. Nurses were also encouraged to assist patients with using handrub that was attached to each patient's bed.

The implementation plan was communicated to the three ward nurses during the roll-call and via the electronic nursing platform over a period of 5 days. This ensured that 80% of the nurses knew about the project implementation. During the implementation, the project team members continued to remind the nurses about the project implementation strategies and encouraged the ward nurses to provide feedback as necessary.

Phase 3: follow-up audit

The 3-month postimplementation audit showed a significant increase in compliance. Sixty-two percent of the audited patients received education in hand hygiene and managed to perform hand hygiene before meals and after toileting or elimination. Figure 2 shows the comparison results of the baseline audit and the postimplementation audit after 3 months.

F2
Figure 2:
Compliance (%) with the best practice for the audit criterion patients have received education regarding hand hygiene at the baseline and follow-up audit cycle 1 (N = 94).

Fisher's exact tests were conducted to determine if there were any statistically significant differences between the values in the baseline audit and the postimplementation audit. There was a significant improvement in the baseline audit and the postimplementation audit (P < 0.05) as shown in Table 3. The proportion of patients who received the MRSA pamphlet during a hand hygiene educational session increased from 64.9 to 89.4% (P < 0.05). The proportion of patients with the perception that hand hygiene is important for reducing infections slightly increased from 93.6 to 94.7%. In addition, the proportion of patients who performed hand hygiene after toileting remained high, whereas the proportion of patients who performed hand hygiene before meals saw a significant increase from 48.9 to 72.3% (P < 0.05). There was also an increase, from 63.8 to 90.4% (P < 0.05), in the proportion of patients receiving the MRSA patient information leaflet in the correct language.

Table 3 - Audit results for patients receiving education regarding hand hygiene at the baseline and follow-up audit 1 (N = 94)
Baseline audit (N = 94) Follow-up audit 1 (N = 94)
JBI criterion #Y %Y #Y %Y χ 2 P value
1. Patients have received education regarding hand hygiene 18 19.1 58 61.7 36.758 0.000
 1.1. Have you received this leaflet? 61 64.9 84 89.4 16.632 0.000
 1.2. Do you think hand hygiene is important/effective in reducing harmful infections? 88 93.6 89 94.7 0.097 1.000
 1.3. When do you practice hand hygiene?
  1.3.1. Before eating 46 48.9 68 72.3 11.786 0.003
  1.3.2. After going to the toilet 87 92.6 93 98.9 5.262 0.065
 1.4. Check completion of patient and family education assessmenta 88 93.6 91 96.8 1.070 0.497
 1.5. Check patient received correct language of the MRSA PIL 60 63.8 85 90.4 19.822 0.000
#Y, number complied with criteria; %Y, percentage complied with criteria; MRSA PIL, Methicillin-resistant Staphylococcus aureus patient information leaflet. Statistical significance was set at P < 0.05.
aTeach/Reinforce or Met within 48 h of admission/transfer to ward.

Discussion

This evidence-based implementation project aimed to improve patients’ participation in hand hygiene practices in the general surgical wards of a Singapore tertiary hospital. The findings from this study showed an increase in number of patients receiving hand hygiene education and practicing hand hygiene. Patients performed hand hygiene in the ward, especially before meals. This suggests that the bedside nurses were diligently conducting hand hygiene education to patients, and patients were also receptive, recognized the importance of hand hygiene22 and willing to take charge of their own health by performing hand hygiene during their stay in the hospital.

Patients’ hand hygiene practices during hospitalization

Practicing hand hygiene among patients and healthcare workers is important. However, it has been a persistent problem for decades as it is not widely practiced in the healthcare industry.23 Traditionally, hand hygiene initiatives or campaigns often focus on healthcare professionals to comply with hand hygiene regulations.7,24 The cause of HAI is multifactorial, yet, patients’ hands have been reported to play a major role in the HAI transmission chain hence this source of HAI should not be ignored.7 Most nurses do not routinely encourage patients to perform hand hygiene before meals and after using elimination aids. Patients with impaired mobility may have difficulties performing hand hygiene as they lack access to hand sanitizer and are afraid to bother nurses when they need assistance to wash their hands.7 In addition, frequent hospital admitters who have received hand hygiene information multiple times may become complacent with maintaining good personal hygiene as they are more focused on their medical treatment plans. Hence, nurses have been proactively offering hand hygiene opportunities to patients, and indirectly informing them of the importance of maintaining good hygiene during their hospital stay.

The trend of including patients in safety initiatives is growing and many studies have shown that patients’ participation in disease management programs is effective in disease control and improving patient outcomes.10 Patients’ and healthcare professionals’ hand hygiene practices are equally important.7 Patients need to be educated on the impact of bacteria on their hands and in the healthcare environment.22 Microorganisms residing on the skin can be transferred from the hand to other surfaces, such as the mouth.22 Through education, patients will develop autonomy and ownership, resulting in better patient participation and patient safety.25 Patients agreed that hand hygiene after toileting is a good personal hygiene habit. Reminders from nurses to perform hand hygiene before meals have shown significant improvement in reducing patients’ risk of acquiring pathogens via ingestion.

This project has successfully encouraged patients to seek assistance when they intend to perform hand hygiene. During both audits, patients perceived hand hygiene as important and effective in reducing harmful infections. Factors that influenced patient participation in hand hygiene practices include behavioral aspects, attitudes, norms and beliefs, as well as the perception of the risk of infection.10,12 Patients with a positive attitude toward hand hygiene practices and good knowledge of hand hygiene practices would regularly practice hand hygiene.26,27 During hospitalization, patients perceived hand hygiene as their least priority compared with their medical issues. Therefore, patients reduced the frequency of performing hand hygiene during hospitalization compared with when at home.27 Mobility problems prevented patients from performing hand hygiene regularly, and some patients were not comfortable requesting assistance from nurses.27 Hence, patients washed their hands only when they were visibly soiled.26 Owing to this, nurses play an important role in encouraging and providing assistance to patients who face difficulty performing hand hygiene themselves.28

Role of nurses in encouraging patients to perform hand hygiene practices

Bedside nurses play a significant role in educating and encouraging patients to perform hand hygiene. To improve nurses’ compliance of providing hand hygiene education to patients, the project team ensured that resources, such as the PIL, were placed in a more accessible location and were regularly replenished. Nurses used PIL of the correct language and the teach-back method to educate their patients. The presence of proper documentation enabled a constant and cyclical evaluation of patients’ learning outcomes.29 These strategies improved patients’ knowledge on hand hygiene practices. Nurses’ reminders to encourage patients to perform hand hygiene were part of the provision of daily fundamental nursing care activities, hence patients were motivated to perform hand hygiene during their hospitalization stay. Consequently, there were improvements in patients’ behaviors, such as their willingness to request nurses’ assistance to perform hand hygiene after toileting or before meals. As such, the intervention demonstrates that education and engagement empower patients to take ownership of their health, and their appreciation for hand hygiene consequently improves patient safety.

Limitations

The project had several limitations. Firstly, this project was implemented over a period of 6 months at only three surgical wards. Secondly, only patients who spoke and understood English and Mandarin were identified and participated in the audit. Lastly, the three surgical wards consisted of patients from diverse backgrounds and ethnicities. Therefore, a project group that consists of members who are multilingual or able to converse moderately well in a common dialect would be advantageous.

Conclusion

The results demonstrated significant improvement in patients’ hand hygiene practices during hospitalization in the surgical wards. Nurses continue to play a substantial role in ensuring that patients perform hand hygiene during hospitalization. Patients recognized the importance of hand hygiene, and education has empowered patients to be responsible for their health, thus improving hand hygiene opportunities, such as after using bedside elimination aids and before meals. The support from ward nursing leaders and nurses continues to uphold and maintain the best practices, and improve the quality of nursing care provided to patients. Future projects should investigate hand hygiene practices of frequently admitted patients.

Acknowledgements

The authors would like to extend their sincere gratitude and appreciation to team members, all nursing leaders, nurses and patients from the participating wards.

Conflicts of interest

The authors report no conflicts of interest.

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Keywords:

hand hygiene; patient education; patient participation; quality improvement

© 2021 JBI. Unauthorized reproduction of this article is prohibited.

A video commentary on implementation project titled: How do health professionals prioritise clinical areas for implementation of evidence into practice? The commentary is provided by Andrea Rochon RN, MNSc, Research Assistant, Queen's University, Ontario, Canada