Date of Award

Summer 2022

Document Type

Final DNP Paper

Degree Name

Doctor of Nursing Practice (DNP) in Family Nurse Practitioner



Faculty Chair

Dr. Arlinda Wormely


Dr. Lori McGrath


Dr. Lenora Ashley


Background: Handwashing with soap and running water is one of the most effective ways to prevent diseases and infections spread through touch. Hand hygiene refers to handwashing with soap, water, and other disinfecting agents to prevent infection. According to Chassin et al. (2017), hand hygiene compliance reduces healthcare-associated infections (HAI). Studies show that an increase in handwashing compliance can be correlated to a decrease in healthcare-associated infections. Studies have proven that though it is challenging to link hand hygiene to a reduction in healthcare-associated infections directly to improved hand hygiene compliance, many hospitals have seen a decline in HAIs as the hand hygiene rate of compliance increased.

Purpose: The Doctor of Nursing Practice (DNP) project aims to educate direct healthcare workers in an inpatient psychiatric facility to meet Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards by implementing a hand hygiene protocol to improve hand hygiene compliance.

Methods: This quality improvement project involves a hand hygiene recruitment script posted at the staff office to invite staff to participate. The World Health Organization’s (n.d.) Perception Survey for Health-Care Workers (PSHCW) was used for the pre-and post-assessment to evaluate for insight before and after education. Applied Glow-germ on direct health care workers’ hands and observed staff wash hands using soap and water. An ultraviolet black light (UV blacklight) was used to inspect how well the team washed their hands. The UV black light glows on germs left unwashed. The CDC proper handwashing procedure ("Stop Germs! Wash Your Hands") was used to educate the direct health care workers.

Results: The key result is that the inpatient psychiatric healthcare workers on the day, evening, and night shift were educated and practiced hand hygiene using CDC's and WHO's program that follows categories 1A, 1B, and 1C guidelines. The guidelines meet JCAHO's standards resulting in the organization having established data on hand hygiene performance and an active process for surveillance and monitoring hand hygiene compliance.

Conclusion: The project addressed JCAHO's hand hygiene standards for the facility and meets the 1A, 1B, and 1C categories on hand hygiene compliance. The hand hygiene education, pre and post-test, and performance established data needed to meet JCAHO compliance.

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