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A Research proposal: Intra -hospital hand hygiene promoting scheme. (Before and after study)


A Research proposal:

Intra -hospital hand hygiene promoting scheme. (Before and after study).


To prove the increase of alcohol-based hand rub compliance after hand hygiene promotion scheme.


MRSA infection is caused by Staphylococcus aurous bacteria — often called "staph." MRSA stands for Methicillin-resistant Staphylococcus aurous. It is a strain of Staphlococcus that is resistant to the multiple antibiotics commonly used to treat it. MRSA can increase the fatality rate of hospital patients.

Most MRSA infections occur in hospitals or other health care settings, such as nursing homes and dialysis centers. It is known as health care-associated MRSA. Anonymous (2009) stated that MRSA kills an estimated 20,000 peoples in the United States each year. The superbug, which is resistant to most common antibiotics, can attack wounds and trigger potentially lethal blood stream infections. Community-associated strains, while generally less virulent and susceptible to more antibiotics, can still cause significant morbidity and mortality.

MRSA would prolong the length of stay of hospital because patients accidentally get hospital acquired MRSA. It finally increases the workload of health care professionals. It is worldwide known as the most common infection that may increase patients’ fatality rate and make patient's condition more badly, as state by Anonymous (2009).

So promoting of the hand hygiene alcohol–base rub is a big issue and benefit to the patient among hospitals and aged home care.

MRSA infection can be prevented, and the best prevention is hand washing (Fierer & Hamady 2008). Washing hands thoroughly with soap and water or using an alcohol-based hand sanitizer will prevent transfer of MRSA to other people or environments. According to the above, MRSA is a very serious infection but only need a little effort to prevent. So a hand hygiene promotion scheme will be introduce and post scheme calculating the effect is my proposing activity.

To prove that the relationship between hand hygiene and the MRSA infection rate in hospital, a numerous graphic will be shown in order to compare the before-and-after study associated with Hand Hygiene Training Program by using the observational method to collect the data  of compliance and use the quantitative method to look for the changes of MRSA rate. Furthermore, it also focuses on changing staff’s attitude to Alcohol hand rub.

Aims and Objectives

Infection control inside hospital is a time-saving, cost saving and most important is it helps prevent the extra-suffering on the patient. Through the hand hygiene promoting scheme, we aims to promote hand hygiene culture inside hospital. However, it is important to consider the factors that might hinder this program. Some research shows that hospital staffs believe that alcohol-based hand rub is harmful to the hand, particularly misunderstanding about skin damage (Creedon 2006). With this, the following are the objectives of this research:

  •  identify the importance of hand hygiene;

  •  present the compliance rate of the staffs in clinical area;

  •  show the importance of the hygiene scheme;

  •  analyze and confirm the infection rate and the behavioral change after the scheme; and

  •  break down the misconception that alcohol-based hand rub can cause damage to the hand.

The Research Question

            As respect to many contraindicating findings as discussed above, the main aim of the study focuses on the investigation of the compliance of the staffs in using alcohol-based hand rub. Thus, this is the research question:

            Does the hand hygiene scheme helped to increase the compliance of the healthcare’s daily hand hygiene practice?


Couchman and Dawson (1995) suggested that the proposal can serve a number of purposes. Firstly, the proposal needs to explain the body being approached exactly what is intended.

            Secondly, the research proposal provides an excellent way for the researchers to clarify them thoughts. Thirdly, it provides a guideline for report writing at the end of the research. However, the research proposal should include three components.  1) why the study should be done 2) how to conduct it and 3) what will be the benefits of the study.

 Literature review

Staphylococcus aurous (S. aurous) is a type of bacteria that is commonly carried on the skin or on the nose of healthy people (Talon & Excoffon 2008). According to the Centers for Disease Control and Prevention (CDC) (2005), 25% to 30% of the U.S. population is colonized in the nose with S. aurous; that is, bacteria are present but are not causing an infection. Asymptomatic colonization of S. aurous is far more common than infection. However, when staph bacteria get into the body, it causes risks because they can cause an infection (Weber, 2008).

Based on the serious outcome of infectious disease problem, educating healthcare assistant to follow and obey hygiene instructions, and make it part of daily activity is very important, because it can help in order to prevent the patient from becoming more ill. Picheansathian (2004) reported that there are two studies which showed that the alcohol-based solution is more effective than non-medicated soap in reducing MRSA.

            The study of Pittet et al. (2000) showed that the compliance of the healthcare assistants have improved after implementing hand hygiene training program. It also showed that the benefits of the alcohol-based hand rub to the health care services in clinical areas include improvement in effectiveness, save more time and less skin irritation.

            All of these factors should motivate Staffs to be more willing to follow the hand hygiene practice. It is worth to totally promote and change the Health care assistant’s culture and behavior or even their beliefs (Maskerine & Loeb 2006).

 Bissett (2002) showed a review of the literature which indicates the benefits of alcohol hand rubs: reduction of microbial load, less irritation to the skin of healthcare workers, and are more easily accessible than the conventional methods of hand hygiene. The review also indicates that using alcohol hand rub increases compliance to hand hygiene guideline rates by 25%.

Furthermore, the study of Malekal et al, 2005 stated that Escherichia coli, Klebsiella spp., nonlactose fermenting Gram –negative bacilli, staphylococci and streptococci formed the transient bacterial flora on the hands. Moderate to heavy bacterial density was seen in more than 92.2% of the hands before washing or hand rub application. Conventional hand wash resulted in drastic reduction in the transient bacterial flora on hands in 50% cases whereas alcoholic hand rub achieved the effects in 95% of the samples. With this, it shows that using alcohol hand rub is more efficient and effective in reducing transient bacterial flora and can be done faster than the traditional hand wash method.

Health care providers can become colonized with MRSA but this has a limited role in transmission. As the important of hand hygiene is globally known, we need to spread this message to front line health care professionals with evidence based data to strength the concept to them (Beggs & Shepherd 2009).

            Andrews (2007) mentioned diseases transmission requires a source of mircobes, method of transmission, exposure, an entry portal and a susceptible host. The exposure can be direct or indirect. However, the pathway of diseases transmission is referred to as the “chains of infection “(Timmreck 2002). Infection control focus on breaking it.  MRSA should spread from patient -to -patient through health care worker’s hands. WHO (2006) found that the compliance rate of Hand hygiene is less than 50%. Voss and Widmer(1997) found that overall compliance rate of hand hygiene rarely exceeds 40% due to many reasons such as understaffing, overcrowding, time consuming, inconvenience, skin discomfort, or irritation.

Guihermetti et al (2001) found that the 70 % ethyl alcohol was more effective than non medicated soap for reducing MRSA .In a similar study, Huang et al (1994) compared 80% Ethyl alcohol with liquid soap, the result showed that the removal rate (the percentage of bacteria removed from the MRSA-contaminated finer trips) was noted to be more for ethyl alcohol 99% VS 96%).

The study by Guihermetti et al (2001) showed that a 10% povidone iodine detergent containing 1% iodine had higher removal than 70% ethyl alcohol.

            Voss and Widmer (1997) mentioned that the primary reasons behind the low compliance of hand washing are: time consuming and inconvenient place and position of the sink. Ward staffs spent about 40-80 seconds for hand washing each time. But use of alcohol hand rubs just need 15 seconds.

Skin irritation and dryness

Data from several studies consistently demonstrated that alcohol-based formulations for hand disinfectants are less irritating on skin than washing hands with soap and water or any antiseptic detergents. Frequent use of alcohol can dry the skin, but the addition of suitable emollients to alcohol hand rinses greatly reduces this problem (Picheansathian 2004). One study showed that the efficacy of alcohol-based hand rubs does not impair in respect to hand disinfection when they are used in combination with selected comparable hand care products (Picheansathian 2004).

            Picheansathian (2004) raised that hand hygiene is an important measure in reducing the transmission of nosocomial infections in hospitals, but adherence is poor among health care workers. More rapid and effective hand disinfection procedures have been proposed, such as rubbing with alcohol – however this cause additional problem to the staffs – primarily dry hand. However, the study of Wilawan (2004) reported that four studies found no significant increase in skin problems due to the use of alcohol-based solution. Most of the skin irritation problems could be controlled with more frequent skin care. In addition, one study indicated that after using an alcohol-based hand rubs, there was a significant decrease in dryness of hands (Wilawan 2004). Frequent use of alcohol can dry the skin, but the addition of suitable emollients to alcohol hand rinses greatly reduces this problem. To conduct a systematic review to determine the best available evidence related to effectiveness of alcohol-based solutions for hand hygiene. The specific review questions addressed were. The effectiveness of reducing microorganism compliance with hand hygiene, and the incidence of skin problems.


Polit and Beck (2008) stated that a major strength of quasi experiments is that they are practical. In the real world, it may be difficult, if not impossible, to conduct true experiments. Where it may be difficult to deliver an innovative treatment randomly to some but not to others. Quasi experimental designs introduce some research control when full experimental rigor is not possible. Another advantage of quasi- experiment is that, in our current era of health care consumerism, patients are not always willing to relinquish control over their treatment condition (Polit & Beck 2008). Indeed, there is some evidence that people are increasingly unwilling to volunteer to be randomized in clinical trials (Gross & Fogg cited in Polit & Beck 2008). Quasi experiment designs, because they do not involve random assignment, are likely to be acceptable to a broader group of people. This is, in turn, has implications for the generalizability of the results - but the problem is that the results are usually less conclusive (Polit & Beck 2008). Different from Randomization (also called random assignment or random allocation), it involves placing subjects into treatment conditions at random. Random means that every subject has an equal chance of being assigned to any group. If subjects are placed in groups randomly, there is no systematic bias in the groups with respect to attributes that could affect the dependent variable. Despite this possibility, randomization remains the most trustworthy and acceptable method of equalizing groups (Polit and Beck, 2008). In general, a ward manager is assumes to rub hand more frequently than the health care assistance. This is because of their differences in terms of position and the roles or the tasks that they do in the health care environment.

There are advantages and disadvantages of observational techniques. The greatest advantage is that it is possible to record from actual behavior, either because they ask for reports of behavior, or interpretations of behavior. Observation does have limitations. It is not always possible to predict the occurrence of a spontaneous event and a sudden change in a patient’s condition might make it difficult to continue observation of a nurse’s skills in a particular area by Darling and Rogers (1986).

Picheansathian (2004) showed that the majority of the 23 studies related to effectiveness in reducing microorganisms, 6 to compliance with hand hygiene, 14 to skin problems, and 3 to application time. Time consuming and inconvenience, skin dryness and irritation are the most barriers to alcohol –based hand rub. The heavy workload and high level of healthcare related activities. There are many opportunities for hand washing to prevent the cross infection. WHO (2006) found the frequency of hand washing is different related to different clinical areas. On average, there are 8 and 20 opportunities for hand washing per patient- hour in pediatrics and intensive care unit. Moreover, Susman (2002 cited in Collins) suggested that soap and water is an inconvenient method because the duration of hand washing is quite long.

For skin irritation or damage, WHO(2006) stated that there are 2 major types of skin irritation related to hand washing such as irritant contact dermatitis and allergic contact dermatitis. The most common symptoms include dryness, irritation and itchiness. Some studies showed ~25% of nurses have reported suffer from dermatitis and more than 85% of nurses give a history of skin problems because of the frequent and repeated use of hand hygiene products. Thus, it will discourage the staffs to maintain proper hand hygiene practices.

Subject to above points, the study can be relevant to each specific issue to observe the behavior of staffs in present.


The target group of this study involves all the staffs who working in the X wards of A hospital in Hong Kong. It is totally 70 persons in whole. And the study place is X ward.

Although the sampling is not the whole numbers of medical workers in Hong Kong. The sampling can represent Hong Kong’s medical units because it is a Hospital Authority hospital. Quasi-experimental studies also examine outcomes; however, they do not involve randomly assigning participants to treatment and control groups. Quasi-experimental study might compare outcomes for individuals receiving program activities with outcomes for a similar group of individuals not receiving program activities (Burns & Grove 2001). This type of study also might compare outcomes for one group of individuals before and after the group’s involvement in a program (known as “pre-test/ post-test design”). Quasi-experimental studies (see Appendix 1) can inform discussions of cause and effect, but, unlike true experiments, they cannot definitively establish this link (Moore, 2008). But the whole X ward of A hospital’s staff not a small sampling at all. The sample includes doctors, nurses, and supporting staffs. Clerks and cleaning staffs could be excluded because they have no direct touching to the patients.

Study period

The data collection period lasted for 1 week before scheme and then promotion period is 1 month to introduce the data and facts of serious outcome cause by MRSA and prove with statistic data and the facts, the following 1 week is for the post scheme study period.

Observation and quantitative method is both applied to the study.

Survey Instrument

Our research team use a observational method to count the hand rub compliance inside a ward without inform them ,that means a spot checking will be process , and the researcher will wear a casual wear in everyday 6-8pm visiting hour for 7 days (1 week) period. Not choosing the doctor round time is because difficult to put a “hidden researcher” (people wear in casual clothes) to perform the observational methods. It is good to avoid the Hawthorne effect.

            And the result of compliance numbers will be present by a numerous method. It can achieve the study with no Hawthorne effect to participate the study because they didn’t know when the researcher will come. The standard of compliance is after touching and before touching patient need rub the hand for 15 seconds. An objective observer is most important in such condition and also time the 15 seconds of cleaning time. 15 seconds is enough to kill the bacteria. So nearly no observer bias is inside. The pre and post compliance number will present with a chart to show its effect. Studied method may affect the result of reliability and validity. Use an observer can prevent the bias and maintain the validity of the survey. And the study group will present their behavior naturally.

Machine scanner was used in order to check for the satisfaction of skin quality. It is subjective and no bias. To compare the skin quality pre- scheme and ideally tell the participant, not to use any other detergents or chemicals that will harm to skin in this period .It is quantitative research because the result is only better or poorer. For count the numbers. It is more objective method to prevent bias.

Research Design and Process

Pre- Scheme Phase

1. Before started the study, need to submit the proposal of study and hand hygiene promotion scheme to Human Resources Department in order to obtain the official approval and finance expense in the scheme.

2. perform a preliminary literature review to search the relevant information about the scheme and study.

3. Obtain the retrospective data and information such as MRSA infection rate, cost and the cost spent in hand hygiene products to be use.

Implemental Phase

1. Obtain the data of hand hygiene (compliance rate) before the scheme by using observational method.

2. Update and show to the staffs with relevant information and guideline by different kinds of communication board and talk with updated Charts, data and facts. Mainly the scientific figure of MRSA to give staffs an impact to pay attention to hand hygiene.

3. Introduce the new Hand hygiene products and demonstrate the usage technique. Even try to demonstrate the post skin quality under the microscope lens to show the skin quality to strengthen the staff’s practice of using hand hygiene alcohol-based products. (It will be use a machine to check the skin quality under microscope and the machine will borrow from some company to save the spent).

4. Pilot the new hand hygiene products to the clinical area for 1 month. At the same time, the researcher started to record the compliance of staff. (For 1 week) Use the observational methods to collect the data and analysis it.

5. Reassess and collect the questionnaire and data from staffs use hand hygiene product‘s .Behaviors and the feedback (after using the alcohol –base hand rub at the end of the scheme).

Post Scheme Phase

Evaluate the outcome and behavior changes of the scheme finished.

Review and mapping the finding of the scheme.

Write a study report by bar chat or statistic data.

Available data are forms of information that are collected from existing resources. There are certain advantages by using the available data because it is easier and save time for us to precede a study (LoBiondo and Haber 1993).

Observational methods have a broad applicability. The observational methods can be used to gather a variety of information such as characteristics and conditions of individuals, verbal and non verbal communication behaviors, activities and environmental conditions (Polit & Hungler 2008). However, observational technique can be used to measure a broad range of phenomena. For this case, only mark for has rub hands or absent of rub hands (Polit and Hungler 1993) .Both of the global behaviors and minute aspects of human activities can be applied and it can be made directly through the human senses or with the assist of technical apparatus such as video equipment. However, the nursing study is particularly well suited to observational method and there are many nursing problems that are more suitable to an observational method than self –report approach (Polit and Hungler 1993).

Observational method in this case can prevent the hidden numbers of non-compliance and the staffs and prevent them from telling lie. Quantitative method is simple to count their satisfactory to the skin quality compare with the skin before the scheme. Just count it is better and poorer after the survey. It purely is a quantitative method.

Polit and Hungler (1993) stated that a critical step in participant observation studies is to identify the way to sample observations and to select locations. Usually, a combination of positioning approaches is used such as single positioning means stay in a single location for a period in order to observe the behavior in the location and mobile positioning means follow a target person throughout  a period of time.

A control group there can be saved since the decrease of MRSA incidents can indicate the effect of alcohol hand rubs.

Ethical Considerations

Everyone have their own value and we need to emphasis on it and respect it for individually. While design the research proposal , we need to concern and respect the rights of individuals (control group )such as not to be harmed, to self -determination, of privacy, to confidentiality, to self-respect and dignity, be able to refuse to participate at any stage of research and not to be refuse services (Counchman and Dawson 1995). Verbal consent is obtained instead of a formal black and white consent. And the findings purpose is obvious raise out for the participants clearly noted.


As the resources of this time’s scheme and promotion is the SDR or CQI of Kwoloon west cluster of hospital Authority. it is not a huge numbers of amounts as the sources of spent is alcohol rub as usual. Manpower for this scheme. The staffs to perform the survey. Some stationary need to use. The machine of microscope scanner to inspect the dried skin in the hands was borrowed from others.

Time table






Ethical approval from hospital Executive and the Hospital Authority. Collect pre scheme data




Gathering information from the infection control unit and start promotion and talk





Record the post scheme result and analyze data





This is the estimate budget for this research.



Photocopy of paper

$ 100


$ 50

Employ assistant (survey performer )

$ 1500

Transportation fee

$ 250

Borrow the machine of microgram

$ 0

Total Cost

$ 2350



Andrews N (2007) Breaking the Chain of Infection: Practical and Effective Infection Control. RHD. Periodical, p.S1-11.

Anonymous (2009) Burness Communications; New study finds MRSA on the rise in hospital outpatients, News Rx Health. Atlanta: Dec 13, 2009. pg. 67.

Beggs, C, Shepherd, S & Kerr, K (2009). ‘How Does Healthcare Worker Hand Hygiene Behavior Impact Upon the Transmission of MRSA Between Patients?: An Analysis Using a Monte Carlo Model’, BMC Infectious Disease, vol. May 15, Retrieved May 4, 2010, from .

Bissett L (2002) British Journal of Nursing, Vol. 11, Iss. 16, 12 Sep 2002, pp 1072 - 1077

Burns N and Grove K (2001) The Practice of Nursing Research: Conduct, Critique, and Utilization ( 4th ed.) Philadelphia: W.B. Saunders Company.

Counchman W and Dawson J (1995) Nursing and Health-care Research :A Practical Guide (2nd ed.) London : Bailliere Tindall.

Credon, S (2006), ‘Health Care Workers’ Hand Decontaminatioin Practices’, Clinical Nursing Research, vol. 15, no. 1, pp. 6 – 26.

Darling V H and Rogers J (1986) Research for Practicing Nurses .London,Macmillan Education Ltd.

Fierer, N, Hamady, M & Knight, R (2008), ‘The Influence of Sex, Handedness and Washing on the Diversity of Hand Surface Bacteria’, Proceedings of the National Academy of Sciences of the United States of America, Retrieved May 4, 2010, from

Guihermetti M,Hernand SED, Fukershigen Y, Garcia L B, Cardoso C L(2001) Effectiveness of hand-cleansing agents for removing methicillin-resistant staphylococcus aurous for contaminated hands. Infection Control and Hospital Epidemiology 2001;22(2) : 105-8.

Huang Y, Oie S Kamiya A(1994) Comparative effectiveness of hand –cleansing agents for removing methicillin –resistant staphylococcus aurous from experimentally contaminated fingertips. American Journal of Infection Control; 22(4): 224-27.

Linda B (2002) British Journal of Nursing, Vol. 11, Iss, 16, 12 Sep 2002, pp. 1072-1077.

LoBiondo-Wood G and Haber J (2002) Nursing research : Methods, Critical Appraisal, and Utilization (5th ed.) St. Louis : Mosby.

Mahekal M, Hemvani N, Ukande U, Geed S, Bhattacherjee M, George J,Chitnis D S(2005) Comparison of traditional hand wash with alcoholic hand rub in ICU setup. Indian J critical care med july-september ,2005. Vol 9 issue 3, pg.141.

Maskerine, C & Loeb, M (2006), ‘Improving Adherence to Hand Hygiene Among Health Care Workers’, Journal of Continuing Education in the Health Professions, vol. 26, no. 3, pp. 244 – 251.

McGuckin M ( 2003) Hand hygiene accountability. Nursing Management. Chicago : Apr 2003.Vol.34,Iss. 4;pg. H2,1pgs.

Picheansathian W.(2004) Effectiveness of alcohol-based solutions for hand hygiene Systematic reviews ,Joanna Briggs Institute. Adelaide.:2004 . pg.1,27 pgs.

Pittet D, Hugonnet S, Harbath S, Mourouga P, Sauvan V, Touveneau S, Pernger T V and members of the infection Control Programme (2000) Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet. 356,1307-1312.

Polit D F & Beck C T (2008) Nursing Research. Generating and Assessing Evidence for Nursing Practice (8th ed.) New york: Wolters Kluwer.

Polit D F and Beck C T (2006) Essentials of Nursing Research methods, appraisal, and utilization . Philadelphia : Lippincott Williams & Wilkins.

Polit D F and Hungler B P (1993) Essentials of Nursing Research methods, appraisal, and utilization (3rd ed.) Philadelphia : Lippincott Williams & Wilkins.

Polit, D F & Hungler, B (1999). Nursing Research: Principles and Methods, Lippincott.

Talon, D, Excoffon, L, Tiv, M, Pinçon, A, Gbaguidi-Haoré & Bertrand, X (2008), ‘Environmental Reservoir of Meticillin Resistant Staphylcoccus Aurous in Patients’ Rooms: Potential Impact on Care Practices’, British Journal of Infection Control, vol. 9, no. 5, pp. 10 – 14.

Timmreck, T 2002, An Introduction to Epidemiology, Jones & Bartlett Learning.

Voss A and Widmer A F (1997) No time for handwashing ? Handwashing Versus Alcoholic Rub : Can We Afford 100% Compliance ? Infection Control and Hospital Epidemiology.18,205-208.

 Wilawan Picheore K A (2008 ) Research to results.Quasi-experimental Evaluations part 6 in a series on practical Evaluation methods.

World Health Organization (2006) World Alliance for patient safety WHO Guideline on hand hygiene in health care (advanced draft ) Global patient safety challenge 2005-2006: Clean Care is Safer Care. Geneva : WHO press.


Appendix  1: Dimensions of Quantitative Research Design



Major Features

Control Over Independent Variable









manipulation of independent variable; control group; randomization


manipulation of independent variable; no randomization and/or no comparison group; but efforts to compensate for this lack


manipulation of independent variable; no randomization or no comparison group; limited over extraneous variables

Type of Group Comparison





subjects in group being compared are different people


subjects in group being compared are the same people at different times or in different conditions

Time Frames




data are collected at a single point in time


data are collected at two or more points in time over an extended period

Observance of independent and dependent variables





study begins with dependent variables and looks backward for cause of influence


study begins with dependent variable and looks forward


Naturalistic Setting



data collected in real-world setting


data collected in contrived laboratory setting

Adapted from Polit and Beck (2006, p 179).

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