Running head: PLACEMENT OF ALCOHOL-BASED HAND SANITIZERS

Placement of Alcohol-based Hand Sanitizer Near Entrances

Katie D. VanderVelde
Ferris State University

PLACEMENT OF ALCOHOL-BASED HAND SANITIZERS

Abstract
A clinical question, or PICOT question, was used to show how research can play into evidencebased practice. Through the search of evidence to support quality and safety in nursing a clinical
question was formed. Three nursing research articles were found to support the clinical question
that was related to placement of alcohol-based hand sanitizer near entrances compared with other
locations to improve hand-hygiene compliance of nursing staff. Evidence showed through the
first nursing research that the use of alcohol-based hand rubs was increased in both units with
monitored electronic hand wash counters installed in each room. The second article suggested
that the increase in the use of hand hygiene compliance was not related to the wearable
dispenser, but rather an increase in availability may be an intervention for compliance. The third
article showed that the increase in the use of alcohol-based hand sanitizers by improving
accessibility was strongly recommended for the decrease in the risk of MRSA among neonates.
All three nursing articles helped support the clinical question that more convenient locations and
accessibility of alcohol-based hand sanitizers can improve compliance among nursing staff.

PLACEMENT OF ALCOHOL-BASED HAND SANITIZERS

Placement of Alcohol-based Hand Sanitizer Near Entrances

A clinical question, or PICOT question, helps to integrate evidence with clinical
expertise. Patient preference and values also plays a role in the development of a PICOT
question that would eventually further more evidence-based practice in nursing. Nurses
interpret research findings and use evidence-based research to support nursing decisions. The
purpose of the assignment is to reflect how nursing knowledge is disseminated for use in
personal and professional practice (Singleterry, 214, p. 11).
Clinical Question
Throughout the years of nursing many research has supported the use of alcohol-based
sanitizers in the risk reduction of nosocomial infection in patients with prolonged hospital stay.
Since evidence has been shown that alcohol based-hand sanitizers was the better option with
nosocomial infections, a background question was formulated. However, to fully format a
PICOT question, a more specific clinical question has to be researched. Research on the topic
helps identify how location and accessibility of alcohol-based sanitizers would be a clinical
question to further evaluate. The clinical question from the research is: Does placement of
alcohol-based hand sanitizer near entrances compared with other locations improve handhygiene compliance of nursing staff?
The PICOT question is based on five components. According to one article, the P
identifies the patient population, which in this case is any patient involved with nursing staff.
The I describes the interventions of interest, which is improving hand-hygiene compliance.

PLACEMENT OF ALCOHOL-BASED HAND SANITIZERS

The C is the comparison intervention, which is the alcohol-based hand sanitizers near
entrances compared to other locations. The O is associated with the outcome, which is the
improvement of nursing staff. Lastly, the T stands for time, which varies and could take two
months to even two years (Echevarria & Walker, 2014, p. 18).
The placement of alcohol-based hand sanitizer near entrances compared with other
locations to improve hand-hygiene compliance of nursing staff could greatly affect patient
quality and safety. Evidence-based practice has shown the use of alcohol-based hand sanitizers
does decrease the use of nosocomial infections (Hilburn, Hammond, Fendler, & Groziak, 2003).
However, not all nursing staff use the sanitizer properly or as much as they should to decrease
the infection. If compliance is increased with the use of these alcohol-based sanitizers the rate of
the infections could decrease. Not to mention, many patients are admitted to the hospital
because of infections. Of every 100 hospitalized patients at any given time, 7 in developed
countries would acquire at least one health care-associated infection (World Health Organization,
n.d., p. 1). Healthcare costs could potentially be decreased if not as many patients were admitted
because of nosocomial infections. In addition, better quality and safety for patients would be
received, because hospital-acquired infections would be decreased. The decrease in infection
could provide patients with the care they need that decreases the transmission of infection.
Methodology
The field of Nursing is one of the largest professions that stress the importance of the use
of standard precaution and hand-hygiene as the center of infection prevention. Location and
accessibility of alcohol-based hand sanitizers deals with standard precautions in general nursing
practice. Compliance with the use of hand sanitizers involves primary nursing care rather than

PLACEMENT OF ALCOHOL-BASED HAND SANITIZERS

advanced practice nursing. The PICOT question does not involve infection transmission through
invasive procedures or nosocomial infections. The PICOT question deals with everyday nursing
practice and how alcohol-based hand hygiene can be improved through better location and
accessibility.
The methodology of a paper includes how the research is collected, generated and how
the research is analyzed (Yeditepe University Writing, 2014). The data from all three articles
to support the PICOT question are from CINAHL (Cumulative Index to Nursing and Allied
Health Literature) database. The database is supported by the Ferris Library, so nursing research
is found and identified. The search for the correct evidence to support the PICOT question is
based more on location and accessibility of alcohol-based hand sanitizers rather than if the
sanitizer fights against infection. The research is analyzed through the critique, results, and
findings of all three articles.
Data that is analyzed also involves the identity of what level of evidence each article
provides. Research in nursing provides ways to grow in the field and perform the highest level
of best practice. Evidence-based practice is associated with the level of evidence in nursing
research. As stated in one article, the level of evidence is an important factor in Evidence Based
Practice (EBP). The level of evidence provides a guide so the reader can carefully interpret
results (Burns, Rohrich, & Chung, 2011).
Based on the AACNs evidence-leveling system (2009), the evidence provided by the
first article, Macedo et al. (2012) would be level C. A Level C study is systematic reviews of
descriptive, qualitative, correlational, systematic, or integrative studies with inconsistent results
(Armola et al., 2009). The study performed in Macedo et al. (2012) does not involve a control

PLACEMENT OF ALCOHOL-BASED HAND SANITIZERS

group and is a quasi-experimental study. According to the AACNs evidence-leveling system

(2009), the second article also is considered level C evidence as a quasi-experimental study. The
study does not randomize staff to use or not to use a wearable dispenser, because the study could
not be followed through (Haas & Larson, 2008). The third article provides level B evidence
where a time series analysis is performed in the study. The time series analysis enables factors
that influence the long-term trend of MRSA (methicillin-resistant Staphylococcus aureus)
transmission after the adjustment of cross correlation of time series data (Sakamoto, Yamada,
Suzuki, Sugiura, & Tokuda, 2010, pp. 529-530). Level B evidence are well designed controlled
studies, both randomized and nonrandomized, with results that consistently support a specific
action, intervention, or treatment (Armola et al., 2009, p. 72). The level of evidence in the three
articles is not the highest, but it is almost impossible to have level A evidence, i.e. a randomized
control trial. Level B and C evidence shows that the study could be improved, however the
study performed could be worse, as in level D, E, or F level of evidence.
Discussion of Literature
Critique of Article # 1
The first article by Macedo et al. (2012) is based on the use of a nurse call system to
evaluate hand-hygiene practices. The article is considered nursing research because it identifies
six nursing authors and is related to alcohol hand sanitizers in nursing practice. The study is
approved by Albert Einstein Hospitals Ethics Committee. The clinical problem is easy to
identify and is included in the first sentence of the introduction. The problem states that
improved compliance with hand hygiene by health care staff was needed to decrease risk of
cross-transmission. Only four out of the fourteen references are more than 5 years old from the
article, which helps show that the literature is appropriately reviewed by the authors (Macedo et

PLACEMENT OF ALCOHOL-BASED HAND SANITIZERS

al., 2012). Not to mention, the journal of the article is known for peer-reviewed research with an
impact factor of 2.73 (Elsevier, 2014).
In the article, Macedo et al. (2012), the design used in the study is not a randomized
control trial so there is no study framework. The article describes the study to be a quasiexperimental study in two step-down units, which is appropriate for the study. The amount of
alcohol-based sanitizers used for hand hygiene was monitored by electronic hand wash counters
installed in patient rooms, which is appropriate for the study. However, history could be an
internal threat to validity because the hospital had other strategies and care practices to prevent
infections (Nieswiadomy, 2012). Some event besides the experimental treatment happened
during the course of a study, which influenced the dependent variable. The sample and setting
includes two step-down units between 2009-2010. The East SDU (Step Down Unit) included
mixed health conditions with twenty-two beds. The West step-down unit also had twenty-two
beds however was focused on cardio conditions. The sample is appropriate for the study because
it was in different locations with mixed health conditions. However, the time frame is not
appropriate because maturation was an internal threat to validity (Nieswiadomy, 2012). In
October, 2010 data was missed due to the call system maintenance stop and also in March, 2010
the SDU was closed for fifteen days due to installation of the call system. The number of nurse
visits to each patient room was measured by the nurse call system (Macedo, 2012).
According to Macedo (2012), through data collection a survey of cases of health care
associated infections was performed with active surveillance, which may have not been
appropriate for the study. The Hawthorne effect may have been an external threat to validity
when the survey was performed, because the study participants could have responded in a certain

PLACEMENT OF ALCOHOL-BASED HAND SANITIZERS

manner (Nieswiadomy, 2012). The study participates were aware that they were being observed.
Nominal level of measurement was used to show characteristics, such as length of stay and
nurse: patient ratio, of the east and west SDUs during the study period (Nieswiadomy, 2012).
Since Fisher exact test, or Chi-square test, was used to compare baseline data and the study
period, nominal level of measurement is appropriate for the study (Macedo, 2012).
Results clearly state in Macedo (2012) that the rate of device-related infections showed a
decreased trend. The use of alcohol based hand rubs was increased in both units with monitored
electronic hand wash counters installed in each room. The results did show evidence to support
the PICOT question, however, some limitations and concerns are significant to nursing. The
quasi-experimental design used in the study is a limitation, because a control group is not
considered. In addition, the hospital had other strategies and care practices to prevent infections,
which caused history as an internal threat to validity (Macedo, 2012). Some recommendations
would include making the time frame a little smaller, perhaps a year, so that maturation would
not be an internal threat to validity. Active surveillance may also be a limitation, because it
created the Hawthorne effect (Nieswiadomy, 2012). In addition, more studies related to the
nurse call system would need to be repeated in order to confirm that the evidence can be
furthered into practice.
Critique of Article #2
The second article, Haas & Larson (2008), describes the impact of wearable alcoholbased sanitizers on hand hygiene in an emergency department. The article is considered nursing
research because both authors are nurses, and it talks about hand hygiene in nursing practice.
The study is approved by the institutional human subjects review board. The problem addressed

PLACEMENT OF ALCOHOL-BASED HAND SANITIZERS

is hand-hygiene compliance and the decrease of infection transmission, which is clear and easy
to identify in the last sentence of the abstract. Five out of the nine references are more than five
years old from the article which is a cause for concern. Also there is no information on whether
the article is peer-reviewed, so the literature could be more appropriately reviewed (Haas &
Larson, 2008).
Even though the Haas & Larson (2008) article does not have a study framework, because
it was not a randomized control trial, the design is appropriate for the study. The design
performed in the study is a quasi-experimental design. Observation of the emergency
department staff and hand hygiene is done in a two and a half month period. The sample
includes a total of seven-hundred and fifty-seven hand hygiene opportunities that were observed
over a three month time period. The sample is appropriate because a sample of at least 186 hand
hygiene opportunities is necessary in the baseline for a total of at least 744 observations. Data
was collected by a standard survey that all staff members in the Emergency Department were
invited to participate in, which could be a threat to validity, which is a cause for concern. The
Hawthorne effect is one reason for the improvement in with hand hygiene (Nieswiadomy, 2012).
Nominal level of measurement is used which includes hand hygiene compliance by product used,
professional discipline, indication for hand hygiene, and whether gloves were used
(Nieswiadomy, 2012). The level of measurement is appropriate for the statistical methods used.
Chi-square tests were used to assess differences in hand hygiene compliance among groups
(Haas & Larson, 2008).
According to the Haas & Larson (2008), results clearly state that the increase in the use
of hand hygiene compliance is not related to the wearable dispenser, but rather an increase in

PLACEMENT OF ALCOHOL-BASED HAND SANITIZERS

10

availability may be an intervention for compliance. Some limitations and concerns significant to
nursing that relate to the article include the use of a quasi-experimental design. It would not be
recommended to randomize staff to use or not to use wearable hand sanitizers for compliance.
Also, a recommendation for further practice includes more interventions trialed to confirm
accuracy, since only a single intervention was trialed (Haas & Larson, 2008).
Critique of Article #3
The third article by Sakamoto et al. (2010) is related to the increased use of alcohol-based
hand sanitizers and the MRSA (methicillin-resistant Staphylococcus aureus) infection. The
article is considered nursing research. According to the article, three out of the five nurses have
their degree in nursing, and the article is about hand hygiene pertaining to nursing. The article
does not confirm that it is approved by the International Review Board of ethics. The clinical
problem addressed is to prevent and control MRSA in NICUs (neonatal intensive care units).
The clinical problem is not easy to identify however, once found is clearly stated. Fourteen out
of the thirty references are older than five years from the article date which is cause for concern
(Sakamoto et al., 2010). Even though the article does not state whether it is peer-reviewed, the
journal it came from is known for peer-reviewed research (Elsevier, 2014). The literature could
be more appropriately reviewed by the authors.
The Sakamato et al. (2010) article does not have a study framework, because of the lack
of a randomized control trial. The design used in the study is a prospective study which is
appropriate because the analyzed time series data looks at factors that are associated in the
gradual decrease of MRSA. The prospective study lasted for six years, in the 33-bed NICU of an
acute care hospital with a population of approximately 400,000. During the study period, there

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were a total of 1229 admissions to the NICU. The sample size could be larger since the time
frame was six years, and the hospital had a population of 400,000. Data collection included
records in a database of the number of infants with at least one MRSA positive sample. Only the
first positive culture results were counted. More than 48 hours after admission were considered
nosocomial and counted as incident cases for MRSA (Sakamoto, Yamada, Suzuki, Sugiura, &
Tokuda, 2010, pp. 529-530). Instrumentation could be a huge threat to internal validity with the
results and records put into the database (Nieswiadomy, 2012). The level of measurement used
is interval, because the data shows monthly MRSA incidence rates in the NICU from July, 2003
to July, 2009. Interval level of measurement is appropriate for the analysis of variance statistical
method used in the study (Nieswiadomy, 2012). The statistical analysis compares four
independent variables which were monthly current MRSA rates, monthly mean of the amount of
alcohol-based hand sanitizers used for one patient per day, monthly mean of patient-to-nurse
ratios, and monthly bed occupancy rates (Sakamato et al., 2010).
According Sakamato et al. (2010), results clearly show that the increase in the use of
alcohol-based hand sanitizers by improvement in accessibility is strongly recommended for the
decrease in the risk of MRSA among neonates. Even though the results show a positive deviance
there are some limitations to the study. The results may not have be generalized to other NICUs.
There may be other factors associated with the spread MRSA other than nurse-to-patient contact
and bed occupancy. In addition, the use of pharmacy records could be a threat to validity,
specifically instrumentation, altering the accuracy of the study (Nieswiadomy, 2012). Lastly,
there are prevention measures already in place before the start of the study (Sakamoto et al.,
2010). Some recommendations for translation into practice include active surveillance in

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another acute hospital setting to see whether the MRSA rates of transmission are the same as the
NICU. Also, the time period for the study could be around three years instead of six. A study
performed throughout six years could cause threats to validity, such as maturation
(Nieswiadomy, 2012).

Significance to Nursing
According to the QSEN (Quality and Safety Education for Nurses) Institute (2014),
quality improvement involves the use of improvement methods to design and test changes to
continuously improve the quality and safety of health care systems. In addition, to describe
approaches to change processes of care. For example, design a small test of change in daily
work. Changing the location and availability in the studies performed in each article supports a
design that improves the quality and safety of nursing care. The QSEN Institute (2014) also
defined safety as to minimize risk of harm to patients and providers through both system
effectiveness and individual performance. Better compliance in nursing staff with anti-bacterial
hand sanitizers will minimize the risk of harm to patients through the decrease in infection.
Professional values, relevant healthcare policy, and availability of resources also play an
important role in the quality and safety of patients who required nursing staff. Under standards
of professional performance, standard ten states that the registered nurse contributes to quality
nursing practice, and standard sixteen states that the registered nurse practices in an
environmentally safe and healthy manner (American Nurses Association [ANA], 2010). Quality
in nursing practice involves the use of standard precautions so the patient is safe and free from

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infection. The nurses professional values should include the patient as the center of care. In
order to keep an environment that is safe and healthy the transmission of infection should be
eliminated as best can be. Availability of resources can play an important role in change. Since
the research findings support location and increased availability as a better intervention for
compliance of sanitizer use, the resources that support the evidence can provide a way to further
the intervention.
The ANA (2010) states under health and safety that all should know the health and safety
for both the patient and the health care worker in any setting that provides health care with a
sense of safety, respect, and empowerment. According to the ANAs healthcare policy, not only
the patients but also the nursing staff should feel safe and respected. Nurses could have a busy
load and the use of anti-bacterial sanitizers can be easily forgotten. As evidence shows
compliance can increase with different locations and accessibility of the sanitizer. Nurses may
have a better sense of empowerment when they know the care is being received in a manner that
is safe and more easily achieved. The availability and accessibility of alcohol-based sanitizers in
more convenient locations can create a better environment for both the patient and nurse.
In conclusion, nursing staff should know the importance of quality and safety in the
health work field. With any nursing position that involves bedside care, comes the responsibility
for the nurse to take standard precautions to keep the patient free from infection. It is the nurses
job to make sure he/she is following the correct policies that support evidence-based practice.
Since evidence has shown through three articles that location and accessibility can increase
compliance with nursing staff in the usage of anti-bacterial sanitizers, the quality and safety of
patient care can be improved.

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References
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Sakamoto, F., Yamada, H., Suzuki, C., Sugiura, H., & Tokuda, Y. (2010). Increased use of
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