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YAPNR-50322; No of Pages 5
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Q1 5 University of Miami, School of Nursing and Health Studies, Miami, FL, USA
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6 Faculty of Nursing Health Education Centre Windsor, University of Windsor, Ontario, Canada
7 Received 31 March 2008; revised 2 June 2008; accepted 5 June 2008
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98 Abstract Background: Nurses and other health care providers (HCPs) continue to be noncompliant with the
10 guidelines of proper hand hygiene practices.
11 Purpose: The purpose of this study was to explore the factors associated with hand hygiene
12 compliance among HCPs during routine clinical.
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13 Methods: An observational study was conducted at an oncology hospital to examine hand hygiene
14 practices observed during 612 procedures that were performed by 67 HCPs.
15 Results: Hand hygiene compliance was 41.7% (n = 255) before procedure and 72.1% (n = 441) after
16 the procedure. The overall compliance was only 34.3% (n = 210). Compliance with the standards of
17 hand hygiene was higher in high-risk procedures (odds ratio [OR] = 1.77; 95% confidence interval
18 [CI], 1.18–2.65) and when HCPs were exposed to blood (OR = 1.40; 95% CI, 1.07–1.73).
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19 Conclusion: The findings highlight the need to continue to push compliance with hand hygiene
20 using innovative approaches that go beyond teaching and in-service training.
21 © 2008 Published by Elsevier Inc.
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23 Health care–associated infections (HAIs) continue to (Beggs et al., 2006). Thus, HAIs have been targeted by The 40
24 impact the outcomes of health care in acute care settings American Nurses Association (2006) as an outcome that 41
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25 because of their associated health complications, cost of care, nurses can change or affect in the health care environment. 42
26 and increased mortality (Centers for Disease Control and However, nurses and other health care providers (HCPs) 43
27 Prevention [CDC], 2002). Each year, an estimated 2.5 continue to be noncompliant to the guidelines of proper hand 44
28 million patients in the United States develop HAIs that result hygiene practices, breach aseptic techniques, and misuse 45
29 in 90,000 deaths and cost the health care system an estimated gloves as a substitute for hand hygiene (Larson, Albrecht, & 46
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30 $4.5 to $5.7 billion dollars (Burke, 2003). In spite of O'Keefe, 2005). Although hand washing and the use of hand 47
31 increased survellience for HAIs, good hand hygiene sanitizers have been instrumental to the prevention of HAIs 48
32 compliance that reduces hand-to-hand or hand-to-skin (CDC, 2002), hand hygiene behaviors and compliance of 49
33 contamination remains the most effective way to decrease HCPs have been less than optimal (Larson et al., 2005). In 50
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34 the risk of HAIs. fact, research (Beggs et al., 2006; Sacar et al., 2006) has 51
35 HAIs are a major concern to infection control practi- suggested that hand hygiene interventions have only 52
36 tioners in acute care and outpatient settings. Adequate nurse minimal or temporary effect on hand hygiene behavior. 53
37 staffing, compliance with proper hand hygiene, and Whitby, McLaws, and Ross (2006) reported that one's 54
38 improved surveillance of HAIs are strategies that improve community hand washing behavior, belief in the benefits of 55
39 patient care outcomes and decreases the incidence of HAIs hand hygiene, peer pressure, and role modeling were 56
predictors of proper hand hygiene behaviors in the health 57
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care setting. 58
This study was partially funded by Packaging Concepts Assoc., LLC,
Boynton Beach, FL.
The aforementioned background demonstrates that a 59
⁎ Corresponding author. Tel.: +1 305 284 8347; fax: +1 305 667 3787. plethora of studies pertaining to the issue of compliance 60
E-mail address: dkorniewicz@miami.edu (D.M. Korniewicz). with hand hygiene among HCPs has been conducted. 61
62 However, evidence pertaining to the independent predic- entered the room to provide patient care until completion of 112
63 tors of compliance with proper hand hygiene in acute the procedure and exiting the patient room. Observations 113
64 health care settings is not conclusive. In addition, the included the HCPs' hand hygiene practices, type of 114
65 impact that the use of dependent observations (i.e., data procedure, and risk of or exposure to body fluids. Clinical 115
66 collected from the same group of participants) may have procedures were classified as either high- or low-risk 116
67 on the outcome of such studies is not fully understood. procedures. High-risk procedures included tasks such as 117
68 Thus, the purpose of this study was to explore the factors drawing blood, changing surgical dressing, emptying 118
69 associated with hand hygiene compliance among HCPs urinary bag, and airway suctioning. Low-risk procedures 119
70 during routine clinical events while accounting for the include tasks such as administering oral medications, 120
71 dependent nature of observations. ambulating the patient, and checking intravenous tubes. 121
Risk of exposure was measured as whether an HCP was
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exposed to body fluids (blood, urine, feces, drainage, 123
72 1. Methods emesis, saliva, and sweat). Compliance with proper hand 124
hygiene standards was defined as performing hand hygiene 125
73 1.1. Design before and after a procedure as defined by the by the CDC's 126
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guidelines for hand hygiene in health care settings (CDC, 127
74 An observational study was conducted at a South Florida 2002). Thus, an HCP was deemed compliant with the 128
75 university oncology hospital to explore the factors asso- standards of hand hygiene practice when he or she 129
76 ciated with hand hygiene compliance during routine demonstrated compliance with the standards both before 130
77 practice. The study was reviewed and approved by the and after the procedure. 131
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78 Western Institutional Review Boards and the Office of
79 Human Subjects at the University of Miami. Initially, a 1.3. Data analysis 132
80 convenience sample of 58 regular staff members who work
81 at the oncology center were invited to participate in the Data analysis procedures were performed using the 133
82 study. Of those, 47 (81%) agreed to participate and Statistical Package for Social Sciences computer program 134
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83 provided a written consent. Prior to data collection, three (version 15.0; SPSS Inc, Chicago, IL). Basic descriptive 135
84 research assistants were trained by the principal investigator statistics were performed to describe the demographic 136
85 to ensure that data collection procedures and observations characteristics of the participants. Given the dependent 137
86 of HCPs were consistent. Data were collected from nature of data (612 observations from 47 participants), 138
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87 inpatient and outpatient units during all three shifts (day, generalized estimating equations (GEE) analysis was 139
88 evening, and night) over a 16-week period. The research performed to determine the independent factors associated 140
89 assistants observed HCPs' compliance with hand hygiene with hand hygiene compliance, using a 95% confidence 141
90 both before and after any given clinical procedure. interval (95% CI) as the criterion to establish statistical 142
significance. GEE is a modeling approach that permits the 143
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91 1.2. Variable definitions and instrumentation analysis of correlated data resulting of multiple observations 144
of the same group of participants. Thus, in this study, the unit 145
92 Two questionnaires were developed for the purpose of of the analysis was the number of observations (n = 612) 146
93 this study. The first elicited demographic data pertaining to obtained from the 47 anticipating HCPs. 147
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162 inpatient unit, 68.1% (n = 32) indicated working at medical– Table 2 t2:1
163 surgical floor, and 10.6% (n = 5) indicated working at a General estimating equation of the predictors of hand hygiene compliance t2:2
164 surgical floor. The mean years of experience in health care Variable B SE Wald p OR 95% CI t2:3
165 among the study participants was 16.5 (SD ± 9.47), and their χ2
166 average hand washing per day was 5.45 times (SD ± 2. 83). Used gloves 0.175 0.163 1.15 .283 1.19 0.87–1.64 t2:4
Nursing profession −0.042 0.170 0.06 .803 .96 0.69–1.34 t2:5
High-risk procedure 0.571 0.206 7.65 .006 1.77 1.18–2.65 t2:6
167 2.2. Hand hygiene compliance
Gender female −0.463 0.151 9.47 .002 0.63 0.47–0.85 t2:7
Exposed to blood 0.265 0.143 3.43 .044 1.30 1.07–1.73 t2:8
168 The data suggested that hand hygiene compliance rate Exposed to urine −0.159 0.244 0.43 .514 0.85 0.53–1.38 t2:9
169 was 41.7% (n = 255) before procedure and 72.1% (n = 441) Exposed to feces 0.231 0.221 1.09 .297 1.26 0.82–1.94 t2:10
170 after the procedure. The overall compliance was only 34.3% Exposed to saliva −0.037 0.139 0.07 .790 0.96 0.73–1.27 t2:11
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Exposed to sweat −0.233 0.107 4.78 .029 0.79 0.64–0.98 t2:12
171 (n = 210). Table 1 suggests that 474 (77.5%) of all
Age −0.003 0.012 0.09 .766 1.00 0.97–1.02 t2:13
172 procedures were low risk in nature, whereas 138 (22.5%) Years in health care −0.011 0.010 1.22 .269 0.99 0.97–1.01 t2:14
173 were high risk. The data further suggest that HCPs complied Unit 1.01–3.02 t2:15
174 with the standards of hand hygiene in 210 (34.3%) of all Medical–Surgical 0.555 0.281 3.92 .048 1.74 t2:16
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175 procedures; 133 (21.7%) were low-risk procedures, whereas oncology
Hemato-oncology (Reference) t2:17
176 77 (12.6%) were high-risk procedures. The data in Table 1
177 show that noncompliance occurred despite exposure to
178 blood, urine, saliva, sweat, and feces.
exposure to emesis were not analyzable because they did not 188
179 Table 2 presents the results of the GEE analysis, which
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occur in more than 99% of the observations. 189
180 shows that compliance with the standards of hand hygiene
181 was higher in high-risk procedures (odds ratio [OR] = 1.77)
182 and when HCP was exposed to blood (OR = 1.40). The data 3. Discussion 190
183 also show that females (OR = 0.63) and those exposed to
184 sweat (OR = 0.79) were less likely to comply with hand Our findings suggest that the overall compliance with 191
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185 hygiene. Compliance was about 1.7 times higher in the hand hygiene among our sample was relatively low. This is 192
186 Medical–Surgical oncology units than the hemato-oncology congruent with the findings of others (Gould, Chudleigh, 193
187 units. Data pertaining to admission to intensive care and Moralejo, & Drey, 2007; Maskerine & Loeb, 2006) who 194
reported that HCPs' compliance with proper hand hygiene 195
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t1:8 Exposed to urine to protect themselves more than their patients. In fact, 205
t1:9 No 338 (55.2) 177 (28.9) Whitby et al. (2006) reported that one's own intrinsic belief 206
t1:10 Yes 64 (10.5) 33 (5.4)
about hand hygiene practices impact his or her hand 207
t1:11 Exposed to saliva
t1:12 No 235 (38.4) 152 (24.8) hygiene compliance. It is also possible that HCPs do not 208
t1:13 Yes 167 (27.3) 58 (9.5) perceive their hands to be as dirty before performing a 209
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223 hygiene standards be addressed using strategies and 2007) who suggested that HCPs are more likely to comply 279
224 policies that equally focus on the behavior and knowledge with hand hygiene standards when they perceive increased 280
225 of HCPs. risk and visualize blood or other body fluids. 281
226 Our findings suggest that HCPs had low compliance rate Our findings suggest that females were less compliant 282
227 with hand hygiene despite the fact that they were aware that with hand hygiene practices. This finding is very interesting 283
228 they were visually observed by a second party. Interestingly, given the fact that 89% of compliance, within the subset of 284
229 Jenner et al. (2006) found that HCPs believed their hand observations in which compliance was reported to have 285
230 hygiene behavior was much better than actually observed occurred, was observed in procedures performed by females. 286
231 and that they would be oblivious to hand hygiene campaigns Thus, it is possible that the high percentage of compliance 287
232 if they were already compliant with hand hygiene standards. among female participants was confounded by other 288
Thus, in addition to addressing the behavior nature of variables (i.e., risk level of the procedure and exposure to
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233 289
234 noncompliance, it important that HCPs be constantly blood or feces), and that once these variables were adjusted 290
235 educated and reminded with the CDC guidelines of proper for, the association between gender and compliance with 291
236 hand hygiene standards. Such continuous targeted education hand hygiene was reversed. Thus, the findings of Sax, 292
237 may increase the sensitivity of HCPs to hand hygiene and its Uckay, Richet, Allegranzi, and Pittet (2007), who found that 293
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238 importance to patients' safety. It is important to note, females were more likely (80%) to adhere to hand hygiene 294
239 however, that all participants in our study completed their practices than their male counterparts (20%), are not 295
240 annual mandatory review for exposure to blood-borne necessarily contrary to ours as they may initially appear. 296
241 pathogens and recertification in Occupational Safety and These findings highlight the impact that the choice of data 297
242 Health Administration (OSHA) training 1 month prior to the analysis technique may have on the results. Thus, we 298
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243 initiation of the study. They also received a review of the recommend that investigators carefully consider their study 299
244 CDC hand hygiene guidelines as part of the study protocol. design and the statistical analysis that would best yield valid 300
245 Thus, it is unlikely that lack of compliance with hand inferences and generalizable conclusions. 301
246 hygiene standards in our study was a mere function of lack of Finally, our data suggested that compliance with hand 302
247 knowledge among HCPs. Despite these findings, we hygiene in the medical–surgical oncology units, which 303
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248 recommend that the impact of targeted continuous educa- includes surgical and critically ill patients, was about 1.7 304
249 tional messages on hand hygiene be further explored. times higher than that of the hemato-oncology unit. There is 305
250 Our findings demonstrated that HCPs were not consistent no clear explanation for this finding. However, in our setting, 306
251 in their pre- and postprocedure hand hygiene practices. hemato-oncology patients rarely present with surgical 307
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252 Unfortunately, other authors (Kuzu, Ozer, Aydemir, Yalcin, wounds or require intensive care with invasive devices 308
253 & Zencir, 2005; Raboud et al., 2004) who performed studies such as that required by those admitted to the medical– 309
254 similar to ours, reported compliance rates based on surgical units. Thus, it is possible that HCPs lax their hand 310
255 postprocedure observations only. The lack of uniformity in hygiene practices when they perceive the risk of infection 311
256 the definition of compliance with hand hygiene among presented to or by their patients to be low. 312
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257 various studies only limits the generalizabilty of those Given the observational nature of our study, it is possible 313
258 studies and compromises the ability to compare the findings that participants may have altered their natural hand hygiene 314
259 of those studies. Thus, it is essential that the definition of practice simply because they were aware that those practices 315
260 compliance be carefully defined based on the CDC (2002) were being observed. There is also the potential of observer 316
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261 standards, which requires hand hygiene before and after bias that may have not been completely eliminated despite 317
262 contact with a patients. the fact that all three observers were trained prior to data 318
263 Our findings suggest that HCPs were more likely to collection. Regardless of these limitations, our findings shed 319
264 adhere to hand hygiene standards when they were participat- light on the issue of hand hygiene practices in acute health 320
265 ing in high-risk procedures or exposed to blood. It is care settings and the factors impacting these practices. They 321
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266 however not clear as to why the compliance was lower if the also highlight the need to continue to uphold the issue of 322
267 procedure involved exposure to sweat other than it is compliance with hand hygiene through many innovative 323
268 possible that HCPs tend to perceive sweating to be less risky. approaches that go beyond traditional teaching and in- 324
269 It is also possible that HCPs are more likely to comply with service training. Although health care institutions continue to 325
270 hand hygiene based on their perception of the risk that a require mandated OSHA and infection control in-services 326
271 procedure may present to a patient. That is, when the among HCPs, the lack of follow-up to validate comprehen- 327
272 procedure is risky, HCPs may perceive that the risk of sion of content may indirectly promote poor hand hygiene 328
273 infection is real and subsequently opt to comply with proper behavior. Thus, it is important that relevant training and 329
274 hand hygiene. Such behavior is probably motivated by education include follow-up and evaluation components to 330
275 HCPs' self-preservation beliefs and not their concerns over measure the impact of such training on the practice of HCPs. 331
276 the quality and safety of their patient care. In fact, this In addition, it is important to focus on the issue of behavior 332
277 explanation is supported by other authors (Richards & and make sure that future resources may be directed toward 333
278 Russo, 2007; Santana, Furtado, Coutinho, & Medeiros, video monitoring and reinforcement of behaviors that 334
ARTICLE IN PRESS
D.M. Korniewicz, M. El-Masri / Applied Nursing Research xx (2008) xxx–xxx 5
335 promote compliance with hand hygiene. Such resources may 6. At the completion of the observed clinical/procedure, 426
336 include observational feedback of hand hygiene practices the HCP did which of the following? (Check all that 427
337 among various HCPs, reinforcement of hand hygiene apply): 428
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338 standards, introduction of disciplinary ramifications against 430
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339 violators of those standards, targeted continuing education □ Washed hands □ Used a hand sanitizer □ Neither 434
340 designed for individuals at various educational levels 435
341 (professional vs. nonprofessionals), and the use of new
342 hand hygiene technologies that target behavior of HCPs. References 436
343 Acknowledgments Beggs, C. B., Noakes, C. J., Shepherd, S. J., Kerr, K. G., Sleigh, P. A., & 437
Banfield, K. (2006). The influence of nurse cohorting on hand hygiene 438
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effectiveness. American Journal of Infection Control 34(10), 439
344 We gratefully acknowledge the contribution of our
621–626. 440
345 research assistants Monica M. Lopez and Jim Brack. Burke, J. P. (2003). Infection control—A problem for patient safety. New 441
England Journal of Medicine, 348(7), 651–656. 442
Centers for Disease Control and Prevention. (2002). Guidelines for hand 443
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346 Appendix A. HCP Observation Form hygiene in health-care setting (No. RR-16). Atlanta: CDC; 2002. 444
Gould, D. J., Chudleigh, J. H., Moralejo, D., & Drey, N. (2007). 445
347 Interventions to improve hand hygiene compliance in patient care. 446
348 HCW code number: ___________ Date: ______________ Cochrane Database Systemaic Reviews (2), CD005186. 447
Jenner, E. A., Fletcher, B. C., Watson, P., Jones, F. A., Miller, L., & Scott, 448
349 1. At the beginning of the procedure the HCP did the G. (2006). Discrepancy between self-reported and observed hand 449
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351 following: hygiene behaviour in healthcare professionals. Journal of Hospital 450
Infections 63(4), 418–422. 451
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Kuzu, N., Ozer, F., Aydemir, S., Yalcin, A. N., & Zencir, M. (2005). 452
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357 □ Washed hands □ Used a hand sanitizer □ Neither
Compliance with hand hygiene and glove use in a university-affiliated 453
358 2. The following procedures were completed during the hospital. Infection Control and Hospital Epidemiology 26(3), 312–315. 454
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360 observation (Check all that applies): Larson, E. L., Albrecht, S., & O'Keefe, M. (2005). Hand hygiene behavior 455
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in a pediatric emergency department and a pediatric intensive care unit: 456
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Comparison of use of 2 dispenser systems. American Journal of Critical 457
365 □ assisted patient with toileting □ changed I.V. tubing
Care 14(4), 304–311 (quiz 312). 458
367 □ suctioned patient □ completed dressing change
Maskerine, C., & Loeb, M. (2006). Improving adherence to hand hygiene 459
369 □ assisted physician with □ changed linen, made bed
among health care workers. Journal of Continuing Education in the 460
370 procedures
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389 to (Check all that apply): (2006). Poor hospital infection control practice in hand hygiene, glove 472
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392 utilization, and usage of tourniquets. American Journal of Infection 473
394 □ Blood □ Urine □ Feces □ Saliva Control 34(9), 606–609. 474
396 □ Sweat □ Emesis □ Suction drainage Santana, S. L., Furtado, G. H., Coutinho, A. P., & Medeiros, E. A. (2007). 475
398 □ Drainage from other tubes Assessment of healthcare professionals' adherence to hand hygiene after 476
□ Other_______________________________________ alcohol-based hand rub introduction at an intensive care unit in Sao 477
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Paulo, Brazil. Infection Control and Hospital Epidemiology 28(3), 478
402 4. Approximately, how long did the HCP perform the 365–367. 479
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404 clinical/observed activity? Sax, H., Uckay, I., Richet, H., Allegranzi, B., & Pittet, D. (2007). 480
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407 Determinants of good adherence to hand hygiene among healthcare 481
409 □ b minute □ 2–3 minutes □ 4–6 minutes □ 7–10 minutes workers who have extensive exposure to hand hygiene campaigns. 482
411 □ 11–15 minutes □ 16–20 minutes □ 21–30 minutes Infection Control and Hospital Epidemiology 28(11), 1267–1274. 483
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414 □ N31 minutes: _________ minutes The American Nurses Association. (2006). Nursing-sensitive quality 484
indicators for acute care settings and the ANA's safety and quality 485
415 5. How many times did the HCP change gloves during the initiative. Retrieved December 23, 2006, from http://nursingworld.org/ 486
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417 observed clinical/procedure? search/vfp_search.cfm. 487
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420 Whitby, M., McLaws, M. L., & Ross, M. W. (2006). Why healthcare 488
422 □ None □ One time □ Two times workers don't wash their hands: A behavioral explanation. Infection 489
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425 □ Three times □ More than three times Control and Hospital Epidemiology 27(5), 484–492. 490
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