Nurs Fpx 8030 Assessment 5 Creation of Policy

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There is also concern over patient safety practices in the healthcare system. Nurs Fpx 8030 Assessment 5 Bacteria and other pathogens are among the risks that threaten all patients within hospital facilities. Patients receiving medication in a health facility are bound to develop infections known as HAIs, most of which are caused by gram-negative bacteria. Integrating an education management system in schools enhances teachers’ workload by additional managerial duties, consequently increasing job demands (Peters et al., 2019). It can cause patients to spend more time in the hospital, cost the healthcare system more, and render antibiotics ineffective against certain bacteria. Using data from the World Health Organization, Peters et al. (2020) estimated that HAI incidence ranges from 72 to 775 million, implying a substantial morbidity and mortality burden on the overall global healthcare service delivery systems. To address this patient safety concern, healthcare institutions have employed different guidelines in handling infection, including hand hygiene enhancement plans to lower HAIs. Nevertheless, the given data also indicate that HAIs remain a relevant issue that must be discussed and resolved in the context of healthcare facilities, emphasizing acute care hospitals.

This policy aims to implement a hand hygiene improvement program in the targeted acute care hospitals to reduce the incidence of HAIs among patients and thus address this issue. The revised PICOT question for this policy is as follows: The proposed hypothesis to be tested is as follows: Among patients admitted in acute care hospitals (P), reducing risks of HAIs (O) in 3 months (T) by application of the hand hygiene improvement program (I) rather than applying none infection control measure (C)? Thus, changes in stewardship are necessary, as HAIs remain highly prevalent and significantly affect patient outcomes and healthcare facilities. This policy enhances patient care outcomes by implementing a hand hygiene improvement plan in acute care hospitals to prevent HAIs and reduce costs.

Nurs Fpx 8030 Assessment 5 Population Affected by the Policy

The target population for the current program of implementing enhanced hand hygiene is the patients undergoing treatment in acute care hospitals and the related healthcare workers. This includes those who visit the hospital briefly, for instance, for medical checkups or temporary management of acute conditions (Alanazi et al., 2021). This may also apply to those who need to be admitted for elective surgery or any other procedure requiring hospitalization. Specific eligibility criteria that may exclude this target population for this study may include patients in the community who have been receiving localized care or treatment for a chronic illness in a different system of care for an extended period. Firstly, the samples may not include the target population, often excluding patients in long-term care facilities, rehabilitation centers, or outpatient clinics.

It is also essential to pattern the demographic characteristics of the target population because such factors may influence the extent of change. For people to be served, intervention, research, and conclusion, as informed by a selected population, are applicable (Barnsbee et al., 2018). For instance, elderly patients or those who have weaker immune systems than those of younger patients are more vulnerable to HAIs because of the factor of age(Cristina et al., 2021). They might need other forms of support to help them avoid such risks. For better focus, healthcare providers should define a more detailed target population when developing and implementing a hand hygiene improvement program, especially for patients admitted to acute care hospitals.


Another essential requirement is the provision of precise definitions of all the words and phrases used in the context of a particular policy document to minimize the chances that a layperson in the industry will not understand the document fully. Furthermore, a policy should have most of the terms written clearly to reduce complexity and problems at the legal interpretation stage (Enaohwo, 2020). Definitions of some related difficult words used in HAI prevention guidelines are the following: Definitions of some related difficult words used in HAI prevention guidelines are the following:

Nurs Fpx 8030 Assessment 5 Hospital-acquired infections (HAIs): These are infections that a patient may develop while in health facilities, including hospitals, and are dangerous to those patients who are already immuno-compromised (Peters et al., 2019). Acute care hospitals deliver immediate short-term services needed for treating acute conditions and types of sicknesses and injuries that people suffer from. General surgery, acute cases, or other emergencies are usually treated within Acute care hospitals (Alanazi et al., 2021). This infection control policy relates to enhanced hand hygiene practices among the healthcare staff to eradicate the spread of infectious agents and, therefore, the subsequent development of HAIs. These bacteria develop the ability to adapt and, hence, are unaffected by antibiotics. This can happen because of the abuse or misuse of antibiotics or other drugs, which consequently can raise the infection counterpoint and the chances of treatment failure of deadly infections (Serwecińska, 2020). This term is sometimes used synonymously with a hospital-acquired infection (HAI).

Policy Statement

The policy/plan is to develop an improvement program for Hand hygiene compliance within Acute care hospitals within the next three months. Thus, hand hygiene aims to decrease patient HAIs (Mouajou & EN, MSCI, HCS, S, & Ibn Sina, 2021). Hence, this policy offers a way of enhancing the safety of patients through handling them using practices that are recommended scientifically due to their effectiveness in minimizing the spread of infections. This quality improvement project evaluates compliance with hand hygiene guidelines, which will impact the eradication of HAIs in the next three months after implementing the improvement program. This work has been developed around the critical problem of patient safety – HAIs, which can lead to fatal outcomes, including increased length of stay, higher costs, or bacterium resistance (Rangel et al., 2022). Our goal is to enhance the effectiveness of the delivered care with the help of this policy and support the practice of using evidence-based interventions to provide competent and risk-free services.

 The team should compare the hospital’s existing level of hand hygiene with supplied hand hygiene products at composite hand hygiene compliance and the reason behind non-compliance. Instead, the team should devise a detailed action plan for overcoming the barriers discovered during the assessment process. Such strategies may include education and training, hand hygiene items, and reminders and feedback incorporated into the recommended action plan (Glowicz et al., 2023).

Nurs Fpx 8030 Assessment 5 Educational and Training

As an essential element of infection control, the team should ensure that hand hygiene products, including water, soap, and hand sanitizers, are available within the hospital. It is evident from the WHO that comprehensive hand hygiene with washing hands with soap and water and hand rubbing with alcohol Hand hygiene program has recorded enhanced control in HAIs (Lotfinejad et al., 2021). In educating and training the healthcare providers within the team, the following should be involved: the reasons for adopting hand hygiene, how to perform hand hygiene appropriately, and the hospital standard.

To achieve the compliance step, the team should undertake the following steps as suggested in the action plan: a) Nurs Fpx 8030 Assessment 5 team/observation healthcare worker should routinely give back feedback on the hand hygiene practices of the particular healthcare provider; b) The feedback should be accompanied with other strategies of reminding the particular healthcare provider with laminated posters or electronic alerts. It is recommended that the team update the two masters to monitor compliance with hand hygiene and HAIs in the program. Consequently, an evaluation of the program in question should be done, and then the concerned team in the program should be adjusted. The Hand Hygiene Self-Assessment Framework Tool developed by the WHO WHO WHO, 2023, can be used to ensure the plan is effectively implemented. By evaluating the Standardized Infection Ratio, an analytic tool designed by the Centers for Disease Control and Prevention, an organization can determine the incidence rate of HAIs (Can et al., 2020).

The following are the recommendations for successfully implementing a hand hygiene improvement program. Engaging a multi-disciplinary team of healthcare providers and infection preventionists is essential because hand hygiene improvement is everyone’s responsibility. Nurs Fpx 8030 Assessment 5 specific strategies for hand hygiene, when coupled with adequate supplies of hand hygiene products about which hospital members are knowledgeable and implementing the interventions proffered above, can decrease HAIs (Glowicz et al., 2023).


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Lotfinejad, N., Peters, A., Tartari, E., Fankhauser-Rodriguez, C., Pires, D., & Pittet, D. (2021). Hand hygiene in health care: 20 years of ongoing advances and perspectives. The Lancet Infectious Diseases, 21(8), e209–e221.

Mouajou, V., Adams, K., DeLisle, G., & Quach, C. (2021). Hand hygiene compliance in preventing hospital-acquired infections: A systematic review. Journal of Hospital Infection, 119, 33–48.

Peters, A., Palao, V. C., Lotfinejad, N., & Pittet, D. (2020). WHO year of the nurse and midwife: More clean and educated hands for all. Journal of Infection Prevention, 21(5), 166–169.

Peters, L., Olson, L., Khu, D. T. K., Linnros, S., Le, N. K., Hanberger, H., Hoang, N. T. B., Tran, D. M., & Larsson, M. (2019). Multiple antibiotic resistance as a risk factor for mortality and prolonged hospital stay: A cohort study among neonatal intensive care patients with hospital-acquired infections caused by gram-negative bacteria in Vietnam. PloS One, 14(5), e0215666.

Rangel, K., Cabral, F. O., Lechuga, G. C., Carvalho, J. P. R. S., Villas-Bôas, M. H. S., Midlej, V., & De-Simone, S. G. (2022). Potent activity of a high concentration of chemical ozone against antibiotic-resistant bacteria. Molecules, 27(13), 3998.

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WHO. (2023). Hand hygiene tools and resources. Retrieved: March 23, 2023.

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