Running head: PICOT PAPER

Picot Paper
Jason Conk
Ferris State University

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Abstract

This article is a discussion about developing a PICOT question that pertains to nursing and the
research involved to develop a conclusion of those results. The issued investigated for this paper
is Hospital Acquired Infections and the impact that hand hygiene has on them.
Picot Paper
The purpose of this paper is to show how nurses use professional communication and
collaboration to share and promote the use of evidence based practice to improve professional
practice. This paper is also designed to research a PICOT question and then report the results of
the research and make a recommendation based on the findings. Based on the recommendation
of the research findings, this paper will examine how the findings can be integrated into
professional practice to improve safety and quality in healthcare settings (Singleterry, 2014).
Clinical Question
Hospitals are designed to treat the sick and injured and to help patients heal and recover.
This is the fundamental purpose for a hospitals existence. No one ever goes to a hospital with
the intention of acquiring a disease and becoming ill or worse yet, dying! However, many
people every year become infected with Hospital Acquired Infections (HAIs) and become sick,
resulting in thousands of deaths per year. Pincock, Bernstein, Warthman, and Holst, 2012, report
that nearly 2 million HAIs and 100,000 HAI-related deaths occurring annually in the United
States alone (p. 18). Those are staggering statistics and are a major cause of preventable
morbidity and mortality.

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The reason why so many HAIs are contracted every year and what can be done to solve the
problem is of major concern for everyone that works at or is admitted into a hospital, which is
nearly every single person in America at some point in their lives. Pincock, et al. 2012 state
Proper performance of hand hygiene at key moments during patient care is the most important
means of preventing HAIs (p. 18). Since this is such a major concern for all citizens in the
United States (and worldwide), this will be the focus of this article.
In order to begin researching a topic accurately a PICOT question must be formulated to
address the underlying causes of the problem and to extrapolate a solution. A PICOT question is
an acronym for Patient or Population (P), Intervention (I), Comparison (C), Outcome (O), and
time(T), (Murphy & Clancy, 2012). The PICOT question that will be addressed here is Does
hand washing among healthcare workers before and after patient care, reduce Hospital Acquired
Infections? The (P) is all patients in a given healthcare facility, the (I) is hand washing, the (C)
is alcohol based sanitizer and no washing at all, the (O) is reduced number of HAIs, and (T) is
before and after patient care/interventions.
Methodology
The research conducted for this article was done through extensive searches of online
databases. Primarily CINHAL and PubMed, as those databases contain nursing and medical
journals. At first only nursing exclusive journals were searched as this article applies to nursing.
However, all medical journals were eventually searched as this offered the greatest array of
information. There are many articles published that pertain to nursing, by nurses, in journals that
arent exclusive to the field of nursing. The articles that were eventually chosen were published
in non-nursing exclusive journals.

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Key words used for searching included, Hospital Acquired Infections, HAIs, Infection
Control, Hand Washing, Hand Hygiene, Hand washing/hygiene and Infections, and Infection
Prevention. Thousands of results were found. The search was narrowed down to include only
articles that were published within the last five years, although two articles were used prior to
that date as they were pertinent to this article. Articles were than filtered to only use those that
were authored wholly or at least partially by Registered Nurses. The articles were than filtered
so only those that pertained to RNs were used as opposed to doctors or advanced practice nurses.
Articles with higher levels of evidence as ranked by Quality and Safety in Nursing (QSEN)
were preferred. Do to the nature of hand washing and the ethics that would be involved in order
to perform Random Control Studies on hospital patients did not seem very likely, they were not
needed for the scope of this paper, therefore not exclusively searched for. QSEN ranks Levels of
Evidence from level one; being the highest, to level seven; being the lowest (AACN, 2014).
Ultimately the three articles that were chosen for discussion were level six, while they are not
considered the best levels of evidence they are sometimes the only studies that are available.
Discussion of Literature
Article One
The first article used for research on this paper was Status of the implementation of the
World Health Organization multimodal hand hygiene strategy in United States of America health
care facilities written by Benedetta Allegranzi, Laurie Conway, Elaine Larson, and Didier Pittet.
The article was published in the American Journal of Infection Control. This article is
considered nursing research as two of the four authors are Registered Nurses (RNs) and the
content applies to every day nursing duties.

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The article was in review of The World Health Organizations (WHO) launching of a
multimodal strategy and campaign in 2009 to improve hand hygiene practices worldwide. The
objective was to evaluate the implementation of the strategy in United States health care
facilities. The design of this study was from July through December 2011, US facilities
participating in the WHO global campaign were invited to complete the Hand Hygiene SelfAssessment Framework online, a validated tool based on the WHO multimodal strategy. Of
2,238 invited facilities, 168 participated in the survey (7.5%). A detailed analysis of 129, mainly
nonteaching public facilities (80.6%), showed that most had an advanced or intermediate level of
hand hygiene implementation progress (48.9% and 45.0%, respectively), (Allegranzi et al.,
2012).
This study is very restricted as it is based solely on surveys. However, the research is still
valid as it shows how proactive healthcare workers are at washing their hands to reduce the
number of HAIs. Being this study was based on surveys it is considered an evidence level of six
according to QSEN (Cronenwett, Sherwood, Barnsteiner, Disch, Johnson, Mitchell, and Warren,
2007). The study was peer-reviewed but was not reviewed by an Institutional Review Board
(IRB), but since the study was voluntary and based on surveys, no ethical boundaries were
crossed. The study showed a positive correlation between improved hand washing practices and
reduced instances of HAIs. Despite the low level evidence there is still validity to the study and
improved hand hygiene policies could be initiated at other institutions as there is little to no risk
for adverse side effects.
Article Two

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This article was titled Hand Hygiene Practices in a Neonatal Intensive Care Unit: A
Multimodal Intervention and Impact on Nosocomial Infection authored by Barbara C.C. Lam,
Josephine Lee, and Y.L. Lau and published in the journal Pediatrics. Two of the authors are RNs
and the study pertains to everyday nursing duties, qualifying this as a nursing article.
The design of this study was Problem-based and task-orientated hand hygiene education,
enhancement of minimal handling protocol and clustering of nursing care, liberal provision of
alcohol-based hand antiseptic, improvement in hand hygiene facilities, ongoing regular hand
hygiene audit, and implementation of health careassociated infection surveillance (Lam, Lee,
and Lau, 2004). The sample was a small 12 bed NICU. The measurements included observation
and auditing. Analysis of the data showed Overall hand hygiene compliance increased from
40% to 53% before patient contact and 39% to 59% after patient contact (Lam, Lee, and Lau,
2004). Results of the study showed that HAIs rate decreased from 11.3 to 6.2 per 1000 patientdays.
The study was peer-reviewed and approved by an IRB. Being this study was based on
observation and auditing, it too is considered, level six evidence by QSEN. Despite the very
small sample size, this is pertinent to nursing because nurses provide the majority of the care for
the children in the NICU. Even though this was a very small study, positive evidence was shown
that improved had washing techniques lowered the number of HAIs, further evidence that can be
used to help change policies in other facilities nationwide.
Article Three
The final article is Effectiveness of a comprehensive hand hygiene program for reduction of
infection rates in a long-term care facility by Steven Schweon, Sarah Edmonds, Jane Kirk,

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Carmen Acosta, and Douglas Rowland. The article was published in the journal American
Journal of Infection Control. The article is peer-reviewed and approved by an IRB. Three of the
authors are RNs and the material applies directly to nurses and their duties in long-term care
facilities (LTCF).
This study was conducted in a 174 bed LTCF over the course of 22 months. The methods of
the study included a comprehensive hand hygiene program including increased product
availability, education for health care personnel (HCP) and residents, and an observation tool to
monitor compliance, was implemented (Schweon et al., 2012, p. 40). The results of the study
showed infection rates decrease from 0.97 to 0.53 infections per 1000 resident days following the
intervention.
This study also used observation techniques making it level six evidence, according to
QSEN standards. Just like the previous two studies, this one likewise shows a direct correlation
of decreased incidences of infection with increased hand hygiene techniques. Despite such a low
level of evidence there is still sound proof that improved hand hygiene is beneficial and is
something all healthcare facilities should strive for.
Significance to Nursing
Helping patients to recover from injury and illness are at the forefront of what nurses due.
Above all else, they should Do No Harm. Transmitting infectious pathogens from one patient to
another does indeed cause harm. The spread of diseases and ultimately obtaining HAIs causes
millions of illnesses every year leading to thousands of deaths, most of which are preventable.
Nurses must be vigilant and diligent in their hand hygiene practices in order to control the spread
of HAIs and stick to their code of ethics of Doing No Harm.

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Hand hygiene is a simple and quick act that has tremendous consequences if not followed
properly. The above articles, despite being of lower level evidence provide very sound and
definitive evidence that improved hand hygiene practices equates to lower instances of
infections, ultimately leading to improved outcomes, shorter hospital stays, and lower costs.
While higher levels of evidence studies are typically needed to institute policy change, in this
case it is not necessary and in fact may be unsafe and lead to deadly consequences. Random
Control Studies are considered the Gold Standard of research, but in the case of hand washing
a control group would require no hand hygiene at all. This certainly is not a feasible option as it
would inevitably lead to an outbreak of HAIs and ultimately many deaths.
There really isnt any controversy over the effects of proper hand hygiene it has been proven
time and time again for over a hundred years that increased hand hygiene leads to better patient
outcomes. The real issue here is the adherence to proper hand hygiene techniques.
Implementing simple in-house education programs is something all healthcare facilities could
easily and cheaply provide. Other options include making sure every room and hallway is
equipped with hand sanitizer. Posters and flyers in rooms and on walls can provide helpful
reminders. While none of the article mentioned ultra-violet light as ways to provide hand
hygiene, it is used in many other industries and hospital labs to kill microbes, this may be a
viable option for the future to have little ultra-violet lights right next to the hand sanitizer with
which one could simply run their hands under.
In the end the issue comes down to simple education and compliance with which all
personnel especially nurses need to adhere too. Education is something that must be done on a
continuing basis for all nurses. Hand hygiene education should also be a part of this recurring
education. It is quick, simple, cheap, and effective which can be applied to all healthcare

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facilities. Cronenwett et al. 2007 states Health professionals, using scientific evidence, need to
be able to describe what constitutes good care, identify gaps between good care and the local
care provided in their practices, and know what activities they could initiate (p. 165). Scientific
evidence exists on the efficacy of hand washing and all astute nurses should be able to recognize
the importance of proper hand hygiene and adhere to it, not some of the time, but all of the time.
The American Nurses Association (ANA), 2014 states Code for Nurses is nonnegotiable and
that each nurse has an obligation to uphold and adhere to the code of ethics. If nurses are to
adhere to the golden rule of ethics, Do No Harm then they must obey proper hand hygiene
techniques in order to assure they are not indeed harming their patients by infecting them with
Hospital Acquired Infections.

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References

AACN, (2014). American Association of Critical-Care Nurses. www.aacn.org

Allegranzi, B., Conway, L., Larson, E., Pittet, D. (2014). Status of the implementation of the
world health organization multimodal hand hygiene strategy in united states of america health
care facilities. American Journal of Infection Control, 42 (3). 224-230.
http://dx.doi.org/10.1016/j.ajic.2013.11.015
American Nurses Association. (2010). Nursing: scope and standards of practice. Silver Spring,
MD: Nursesbooks.org
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., Warren, J.
(2007). Quality and safety education for nurses. Nursing Outlook, 55(3), 122-131.
Doi:10.1016/j.outlook.2007.02.006
Lam, B., Lee, J., Lau, Y. (2004). Hand hygiene practices in a neonatal intensive care unit: a
multimodal intervention and impact on nosocomial infection. Pediatrics. 114 (65), 564573. DOI: 10.1542/peds.2004-1107
Murphy, L., Clancy, S. (2012). EBM Guidebook. Medical Student Survival Manual, 24.1-14.
Pincock, T., Bernstein, P., Warthman, S., Holst, E. (2012). Bundling hand hygiene interventions
and measurement to decrease health careassociated infections. American Journal of
Infection Control. 40 (3), 18-27. http://dx.doi.org/10.1016/j.ajic.2012.02.008
Schweon, S., Edmonds, S., Kirk, J., Rowland, D., Acosta, C. (2013). Effectiveness of a
comprehensive hand hygiene program for reduction of infection rates in a long-term care
facility. American Journal of Infection Control, 41 (1), 39-44.
http://dx.doi.org/10.1016/j.ajic.2012.02.010

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Singleterry, L. (2014). NURS 350. Nursing Research, [Syllabus].

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