NUR2300 5As Step of Evidence-Based Nursing Practice Assessment 1 Answer

INTRODUCTION

Evidence-based practice is important in providing effective care aiming to improve the patient outcome. Hand hygiene should be an essential part of the scope of routine practice. Hand hygiene should be followed as per the appropriate protocols by WHO to avoid the contamination and hospital-acquired infections. Methicillin-resistant staphylococcus aureus (MRSA) is the commonest cause of hospital-acquired infection and has been isolated from the hands of health care workers (Adegboye et al., 2018). Hospital-acquired infections are the infections that are obtained by the individual during the stay in the hospital.  This essay emphasizes on the 5A’s step of evidence-based practice approach to reach a solution related to low compliance of healthcare professionals with the hand hygiene and how it can have a negative impact on the patient using hospital-acquired infection as a parameter.

ASK

To follow the 5A’s evidence-based practice approach in nursing the foremost step is to ask a clinical question that represents the clinical problem. The clinical question for best results should follow the PICOT format. PICOT format allows addressing the problem in the cross-sectional informational dimension specific to the negative impact of handwashing non-compliance among healthcare professional (Eriksen & Frandsen, 2018). PICOT is the acronym, use for a problem or patient population; an intervention that has been adopted; the comparison is the correlation between the attributes which enhance the validity of the question; the outcome is the results which needs to be established and Time is period for which observation is done to establish the study. Hence the question is “Does handwashing among the healthcare professionals in the medical ward can reduce the incidence of hospital-acquired infections?” The problem is hospital-acquired infections, intervention is hand washing, the comparison is no hand hygiene or Lower compliance and outcome is lower infection rate.

ACCESS

This step is about converting the well-built clinical question into a search strategy for finding relevant researches. Once the search strategy is formulated suitable resources were identified.  To find the answers pre- appraised resourced were used in the beginning starting from the top of the hierarchy moving down if required. To find the evidence-based research articles on hospital-acquired infection and hand hygiene the databases like CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PubMed were utilized. Most of the search was focused on PubMed with articles focusing on nursing compliance and intervention. The initial search was done in the viewpoint of the first two elements of the PICOT question representation of the problem and intervention. Then moving further, the composition and outcome of the clinical question were browsed. The information was collected through abstract as well as the full text of the article to establish the comparison and outcome. The methodology of simple keyword search was adopted, concept 1 and concept 2 were searched (de Groot et al., 2013). The keyword used for concept 1 were hospital-acquired infection, cross-infection and nosocomial infection. For concept 2 the keyword used were handwashing, hand disinfection, hand hygiene and hand scrubbing. Initially, both the keywords were used separately as cumulative use can restrict the article citations. However, after viewing the initial article the search was narrowed down to include the comparison and outcome. 

Also, to narrow down the keyword was used together with the help of connecting words like “and”. Later for the proper translation of information keywords based on both simple and MeSH (Medical Subject Headings) term was considered. Researches were included based on the hierarchy of evidence they provided. Systemic reviews, meta-analysis and critical appraisal were considered first being a filtered information source and higher in the hierarchy (Murad et al., 2016). Then randomized control trial and cohort studies were taken. The resource hierarchy was considered while selecting the article to restrict maximum hindrance to the quality of the information. Being a free database for filtered and unfiltered information thorough search schema was required for effective searching. Next in all databases, the categorical Limit feature was explored for example nurses, physician and surgeons. Then filter for article type was used like RCT or systemic review. 

These steps were intended to narrow down the information available for the highest level of evidence. Over the search option, the clinical question was searched using the operators' words such as OR, AND, NOT etc. The category filter was kept on for narrowing the information resources. The filters used were the text availability, article type, publication date and journal category. The text availability was kept on full text; article type selected was the systemic review, RCT and metanalysis; time 10 years and journal category on Nursing journal. After initial unsatisfactory results. The filter for the nursing journal was removed which yielded a higher number of evidence researchers. The search yielded 15 articles, and after inclusion criteria 6 remained out of which 3 were selected for intensive study and critical appraise.

APPRAISE

The first article was a peer-reviewed study done by Sopirala et al., 2014. It is level 6 evidence on the evidence-based pyramid. The research was well established through literature review. They identified the gap between non-compliance and unawareness among the workers. After the implementation of the intervention, they found a 28 percent decrease in MRSA infections. Compliance of 93 percent was reached from 30 percent. The data was converted with precise and clear statistical means however the validity of the result may have potential drawback of Rosenthal effect (when participants knew they are being observed they become conscious to perform the desired activity) as participants were under constant observation. 

The second study by Gould et al., 2017 is the systemic review which includes 26 studies from PubMed, Embase, CINAHL from 2009 to 2016. Fourteen studies were focused on assessing the WHO recommended strategies of hand hygiene as the intervention. Six studies evaluated performance and two monitored the education level.  The study found the compliance was much higher with the simplex intervention versus the multimodal technique. However, the result could not be established well due to low certainty of the evidence found regarding the factors influencing the compliance.

The third review of Luangasanatip et al., 2015 is a systemic analysis and network meta-analysis of studies conducted from 2009 to 2014. The database for selection was Medline. Embase, CINAHL and Cochrane Library. It is level 6 evidence on pyramid being a metanalysis and systemic review. The study consists of articles which measure the compliance of workers to the 2005 WHO protocol of hand hygiene. Having five steps of handwashing. Most of the studies suggested stepwise implementation yielding higher results. Although nineteen studies reflected the decrease in infection rate, however, not for all pathogens. The detailed information of pathogens was not found.

APPLY

The enabler for the implementation or adoption of the intervention among the staff was majorly the perception of social pressure to perform hand hygienic. Vigilance over the professionals in terms of responsibilities and incentives have resulted in better compliance. The literature also recommended that if hand hygienic is added as the part of workflow and professionals were provided extra time, the compliance has increased. Also, proper awareness campaign and education inculcating the belief of effectiveness of hand hygiene motivated the professionals to adopt the practice in routine.

Overburden and long working shifts came as the biggest barrier to intervention implementation. Attitude and perception were also a barrier to implementation. Health professionals believed that after removing the gloves hand hygiene was necessary but not before it, leading to incomplete adherence to process. Also, many healthcare professionals being overburdened with the number of patient care resisted as they believed quick and target performance was more important than hand hygiene. Healthcare professionals are expected to perform hand hygiene before checking the patient, after checking the patient, wearing any equipment gloves, masks, gowns and after it.  Another barrier in multiple hospitals was the absence of handwashing sinks accessibility where they need to wash hands. In such cases, professionals end up looking for another location in their busy environment which cause distraction and low compliance. 

ASSESS

Out of the two studied analysed the data cannot be established in terms of validity in implementation of the intervention hence deteriorating the quality of the study. Also, in the third study, the implementation in terms of direct impact was not established as pathogens or hospital-acquired infection details were not provided.  The first study depicted an implementation rate of 93 percent with a reduction of MRSA rate in the intervention period. The literature included the small sample size which could affect the generability of the study result. Hence the success of the intervention could not be established. The pressure of being observed to perform the hand hygiene activity causes short period compliance where long term result could not be established in the study. As the intervention period was shorter compliance cannot be reflected as a part of attitude and behaviour change.

CONCLUSION

As healthcare professionals services should be provided through evidence-based practices. To reduce the incidence of hospital-acquired infection evidence-based practices are required. To achieve handwashing compliance the implementation should be through the elimination of associated barrier for the non-compliance. An important step for establishing the handwashing compliance is through education and promotion. The reviewed studies indicated the gap in the study done in the subject area and the need for future studies. Studies in future should evaluate various aspects of intervention implementation like enablers, challenges and barrier for authenticating the study.