Researching safety culture: deliberative dialogue with a restorative lens.

Safety culture is a key component of patient safety. Many patient safety strategies in health care have been adapted from high-reliability organizations (HRO) such as aviation. However, to date, attempts to transform the cultures of health care settings through HRO approaches have had mixed results. We propose a methodological approach for safety culture research, which integrates the theory and practice of restoration science with the principles and methods of deliberative dialogue to support active engagement in critical reflection and collective debate. Our aim is to describe how these two innovative approaches in health services research can be used together to provide a comprehensive effective method to study and implement change in safety culture. Restorative research in health care integrates socio-ecological theory of complex adaptive systems concepts with collaborative, place-sensitive study of local practice contexts. Deliberative dialogue brings together all stakeholders to collectively develop solutions on an issue to facilitate change. Together these approaches can be used to actively engage people in the study of safety culture to gain a better understanding of its elements. More importantly, we argue that the synergistic use of these approaches offers enhanced potential to move health care professionals towards actionable strategies to improve patient safety within today's complex health care systems.

Characteristics of nursing professionals and the practice of ecologically sustainable actions in the medication processes.

Objectives: to verify the correlation between the characteristics of professionals and the practice of sustainable actions in the medication processes in an ICU, and to determine if interventions such as training and awareness can promote sustainable practices performed by nursing staff in the hospital. Methods: before-and-after design study using Lean Six Sigma methodology, applied in an intensive care unit. Nursing staff were observed regarding the practice of ecologically sustainable actions during medication processes (n = 324 cases for each group (pre and post-intervention)) through a data collection instrument. The processes analyzed involved 99 professionals in the pre-intervention phase and 97 in the post-intervention phase. Data were analyzed quantitatively and the association of variables was accomplished by means of statistical inference, according to the nature of the related variables. Results: the education level was the only characteristic that showed to be relevant to an increase in sustainable practices, with a statistically significant difference (p = 0.002). When comparing before and after the intervention, there was an increase in environmentally friendly actions with statistically significant differences (p = 0.001). Conclusions: the results suggest that institutions should encourage and invest in formal education, as well as training of health professionals to promote sustainable practices in the hospital.

Characteristics of nursing professionals and the practice of ecologically sustainable actions in the medication processes / Características de los profesionales de enfermería y la práctica de acciones ecológicamente sustentables en los procesos de medicación / Características dos profissionais de enfermagem e a prática de ações ecologicamente sustentáveis nos processos de medicação

ABSTRACT Objectives: to verify the correlation between the characteristics of professionals and the practice of sustainable actions in the medication processes in an ICU, and to determine if interventions such as training and awareness can promote sustainable practices performed by nursing staff in the hospital. Methods: before-and-after design study using Lean Six Sigma methodology, applied in an intensive care unit. Nursing staff were observed regarding the practice of ecologically sustainable actions during medication processes (n = 324 cases for each group (pre and post-intervention)) through a data collection instrument. The processes analyzed involved 99 professionals in the pre-intervention phase and 97 in the post-intervention phase. Data were analyzed quantitatively and the association of variables was accomplished by means of statistical inference, according to the nature of the related variables. Results: the education level was the only characteristic that showed to be relevant to an increase in sustainable practices, with a statistically significant difference (p = 0.002). When comparing before and after the intervention, there was an increase in environmentally friendly actions with statistically significant differences (p = 0.001). Conclusions: the results suggest that institutions should encourage and invest in formal education, as well as training of health professionals to promote sustainable practices in the hospital.

RESUMEN Objetivos: verificar la correlación entre las características de los profesionales y la práctica de acciones sustentables en los procesos de medicación en una UTI y determinar si intervenciones como capacitación y concientización logran promover la práctica de acciones sustentables por el equipo de enfermería en el hospital. Métodos: estudio antes y después usando la metodología Lean Seis Sigma, aplicada en una unidad de terapia intensiva. El equipo de enfermería fue observado referente a la práctica de acciones ecológicamente sustentables durante los procesos de medicación (n = 324 casos de cada grupo (pre y post-intervenciones) mediante un instrumento de recolecta de datos. Los procesos analizados involucraron 99 profesionales en la fase de post-intervención. Los datos fueron analizados cuantitativamente y para asociar las variables fue aplicada la estadística inferencial, según la naturaleza de las variables relacionadas. Resultados: el nivel de escolaridad fue la única característica que se mostró relevante para el aumento de prácticas sustentables con diferencia estadísticamente significativa (p = 0,002). En la comparación antes y después de las intervenciones, aumentaron las acciones ecológicamente correctas con diferencia estadísticamente significante (p=0,001). Conclusiones: los resultados sugieren que las instituciones deben estimular e invertir en la educación formal, y también en la capacitación de los profesionales de salud para la promoción de prácticas sustentables en los hospitales.

RESUMO Objetivos: verificar a correlação entre as características dos profissionais e a prática de ações sustentáveis nos processos de medicação em uma UTI e determinar se intervenções como treinamento e conscientização podem promover a prática de ações sustentáveis realizadas pela equipe de enfermagem no hospital. Métodos: estudo antes e depois usando a metodologia Lean Seis Sigma aplicada em uma unidade de terapia intensiva. A equipe de enfermagem foi observada referente à prática de ações ecologicamente sustentáveis durante os processos de medicação (n = 324 casos de cada grupo (pré e pós-intervenções)) por meio de um instrumento de coleta de dados. Os processos analisados envolveram 99 professionais na fase de pré-intervenção e 97 na fase de pós-intervenção. Os dados foram analisados quantitativamente e a associação das variáveis foi realizada por meio de estatística inferencial, de acordo com a natureza das variáveis relacionadas. Resultados: o nível de escolaridade foi a única característica que se mostrou relevante para o aumento de práticas sustentáveis com diferença estatisticamente significativa (p = 0,002). No comparativo antes e após as intervenções, houve um aumento das ações ecologicamente corretas com diferença estatisticamente significante (p=0,001). Conclusões: os resultados sugerem que as instituições devem estimular e investir na educação formal, assim como no treinamento dos profissionais de saúde para a promoção de práticas sustentáveis nos hospitais.

Contributions of the sandwich doctoral program to methodological approaches: an experience report. / Contribuições do programa de doutorado sanduíche nas abordagens metodológicas: relato de experiência.

Objective To share our experience on theoretical and methodological insights we have gained as researchers working together during the Sandwich Doctoral Program. Method This is a descriptive experience report. Results We have incorporated restoration thinking into a study on patient safety culture and will enhance knowledge translation by applying principles of deliberative dialogue to increase the uptake and implementation of research results. Conclusion Incorporating new approaches in Brazilian nursing research plays a key role in achieving international participation and visibility in different areas of nursing knowledge.

Sustentabilidade ambiental nos processos de medicação realizados na assistência de enfermagem hospitalar / Environmental sustainability in medication processes performed in hospital nursing care

Resumo Objetivo Foram analisadas ações sustentáveis realizadas pela equipe de enfermagem de uma unidade de terapia intensiva durante os processos de medicação e proposto intervenções para a melhoria da sustentabilidade ambiental na área hospitalar. Métodos Estudo antes e depois usando a metodologia Lean Seis Sigma aplicada em uma unidade de terapia intensiva. A amostra foi composta por 648 processos de medicação realizados pela equipe de enfermagem. Os dados foram coletados por meio de roteiros de observação e analisados quantitativamente. Resultados Os resultados pós-intervenções incluíram a redução dos materiais como sacos plásticos (37,1%), redução de sobras de anti-inflamatórios hormonais (67,1%), aumento na remoção de etiquetas de sacos plásticos para serem reciclados (146,9%) e descarte correto de resíduos (32,2%) com diferença estatística significante (p ≤0.05). Conclusão As estratégias de intervenções implementadas a partir da análise do problema, validação e priorização das ações teve influência positiva na redução, reciclagem e disposição correta dos resíduos com benefícios para a instituição, meio ambiente e a saúde humana.

Abstract Objective Sustainable actions performed by the nursing team in an intensive care unit during medication processes were examined, after which interventions were proposed to improve environmental sustainability in the hospital setting. Methods Before and after study, using the Lean Six Sigma methodology applied in an intensive care unit. The sample was comprised of 648 medication processes performed by the nursing team. The data was collected via observation routes and analyzed quantitatively. Results The post-intervention results included: reduction of materials such as plastic bags (37.1%), reduction of hormonal anti-inflammatory drugs (67.1%), increased removal of labels from plastic bags to be recycled (146.9%) and proper waste disposal (32.2%), with a statistically significant difference (p ≤0.05). Conclusion The intervention strategies implemented, based on an analysis of the problem, validation and prioritization of the actions had a positive influence on reduction, recycling and proper disposal of waste with benefits for the institution, environment and human health.

Contribuições do programa de doutorado sanduíche nas abordagens metodológicas: relato de experiência / Contribuciones del programa de doctorado sándwich con los abordajes metodológicos: relato de experiencia / Contributions of the sandwich doctoral program to methodological approaches: an experience report

RESUMO Objetivo Compartilhar experiências e insights teóricos e metodológicos que os pesquisadores obtiveram ao trabalhar juntos durante um programa de doutorado sanduíche. Método Trata-se de um estudo descritivo do tipo relato de experiência. Resultados Incorporou-se o pensamento restaurativo no estudo da cultura de segurança do paciente e espera-se implementar o plano de knowledge translation utilizando os princípios do diálogo deliberativo como uma estratégia para aumentar a aplicabilidade dos resultados da pesquisa. Conclusão A incorporação de novas metodologias nas pesquisas da enfermagem brasileira possui um papel fundamental para o alcance de visibilidade e participação internacional nas diferentes áreas de conhecimento da enfermagem.

RESUMEN Objetivo Compartir experiencias e introspecciones teóricas y metodológicas que los investigadores obtuvieron al trabajar juntos durante un programa de doctorado sándwich. Método Estudio descriptivo del tipo relato de experiencia. Resultados Se ha incorporado el pensamiento restaurador en el estudio de la cultura de seguridad del paciente y se espera implementar el plan de traducir conocimientos usando los principios del diálogo deliberativo como una estrategia para aumentar la aplicabilidad de los resultados de la investigación. Conclusión La incorporación de nuevas metodologías en las investigaciones de enfermería brasileña tiene un rol fundamental para el alcance de visibilidad y participación internacional en las diferentes áreas de conocimiento de enfermería.

ABSTRACT Objective To share our experience on theoretical and methodological insights we have gained as researchers working together during the Sandwich Doctoral Program. Method This is a descriptive experience report. Results We have incorporated restoration thinking into a study on patient safety culture and will enhance knowledge translation by applying principles of deliberative dialogue to increase the uptake and implementation of research results. Conclusion Incorporating new approaches in Brazilian nursing research plays a key role in achieving international participation and visibility in different areas of nursing knowledge.

Engaging nurses to strengthen medication safety: Fostering and capturing change with restorative photographic research methods.

We used participatory photographic research methods adapted from the field of ecological restoration to engage Brazilian intensive care unit nurses in a critical review of medication safety in their work environment. Using focus groups, practitioner-led photo walkabouts with photo narration, and photo elicitation focus groups in iterative phases of data collection and analysis, nurses developed and implemented several practical and cultural improvements for their unit. Participants focussed on organizing the medication room for efficient workflow and accessible supplies, improving reporting practices, and reconsidering how they could manage safety issues in their unit and in the hospital as a whole. Our results demonstrated that restorative photographic research methods enabled participants to (re)think and redesign their work environment in keeping with several recommended practices for improving medication management. It also validated the need for continuous evidence-informed improvements if nurses hope to optimize medication safety in the complex systems of intensive care.

Nursing workload and patient safety--a mixed method study with an ecological restorative approach.

OBJECTIVE: The aim of this study was to analyze the potential association between nursing workload and patient safety in the medical and surgical inpatient units of a teaching hospital. METHOD: a mixed method strategy (sequential explanatory design). RESULTS: the initial quantitative stage of the study suggest that increases in the number of patients assigned to each nursing team lead to increased rates of bed-related falls, central line-associated bloodstream infections, nursing staff turnover, and absenteeism. During the subsequent qualitative stage of the research, the nursing team stressed medication administration, bed baths, and patient transport as the aspects of care that have the greatest impact on workload and pose the greatest hazards to patient, provider, and environment safety. CONCLUSIONS: The findings demonstrated significant associations between nursing workload and patient safety. We observed that nursing staff with fewer patients presented best results of care-related and management-related patient safety indicators. In addition, the tenets of ecological and restorative thinking contributed to the understanding of some of the aspects in this intricate relationship from the standpoint of nursing providers. They also promoted a participatory approach in this study.

Nursing workload and patient safety - a mixed method study with an ecological restorative approach / Carga de trabalho da equipe de enfermagem e segurança do paciente - estudo com método misto na abordagem ecológica restaurativa / Carga de trabajo de enfermería y seguridad de pacientes - estudio con método mixto y aproximación ecológica restaurativa

OBJECTIVE: The aim of this study was to analyze the potential association between nursing workload and patient safety in the medical and surgical inpatient units of a teaching hospital. METHOD: a mixed method strategy (sequential explanatory design). RESULTS: the initial quantitative stage of the study suggest that increases in the number of patients assigned to each nursing team lead to increased rates of bed-related falls, central line-associated bloodstream infections, nursing staff turnover, and absenteeism. During the subsequent qualitative stage of the research, the nursing team stressed medication administration, bed baths, and patient transport as the aspects of care that have the greatest impact on workload and pose the greatest hazards to patient, provider, and environment safety. CONCLUSIONS: The findings demonstrated significant associations between nursing workload and patient safety. We observed that nursing staff with fewer patients presented best results of care-related and management-related patient safety indicators. In addition, the tenets of ecological and restorative thinking contributed to the understanding of some of the aspects in this intricate relationship from the standpoint of nursing providers. They also promoted a participatory approach in this study.

OBJETIVO: analisar a carga de trabalho da equipe de enfermagem e sua potencial relação com a segurança do paciente, em unidades de internação das áreas clínica e cirúrgica de um hospital universitário. MÉTODO: adotou-se um método misto de pesquisa com desenho sequencial explanatório. RESULTADOS: a etapa quantitativa inicial do estudo sugere que o aumento do número de pacientes designados para a equipe de enfermagem implica em aumento das taxas de queda do leito, infecções relacionadas ao cateter vascular central, rotatividade de profissionais e absenteísmo. Durante a etapa qualitativa subsequente, a equipe de enfermagem destacou os cuidados relacionados à administração de medicação, banho de leito e transporte de pacientes, como aqueles que mais repercutem na carga de trabalho e mais representam riscos para a segurança do paciente, dos profissionais e do ambiente. CONCLUSÕES: os achados deste estudo evidenciaram associações significativas entre carga de trabalho e a segurança dos pacientes. Observa-se que os quadros de pessoal com menos pacientes apresentaram os melhores indicadores de qualidade assistencial e gerencial de segurança do paciente. Além disso, os princípios do pensamento ecológico e restaurativo contribuíram para a compreensão de alguns dos aspectos envolvidos nessa intricada relação, a partir dos olhares dos próprios profissionais e também promoveram abordagem participativa para o estudo desse tema.

El estudio tuvo por objetivo analizar la carga de trabajo de enfermería y su potencial relación con la seguridad del paciente en unidades de internación de las áreas clínica y quirúrgica de un hospital universitario. Se adoptó un método mixto de investigación con diseño secuencial explicativo. Los resultados de la etapa cuantitativa indican que el aumento del número de pacientes atribuidos al equipo de enfermería implica en elevación de las tasas de caída de cama, infección relacionada a catéter vascular central, turnover y absentismo. En la etapa cualitativa, el equipo de enfermería destacó los cuidados relacionados con la administración de medicación, baño de cama y transporte de pacientes como aquellos que más repercuten en la carga de trabajo y representan riesgos para la seguridad de los pacientes, de los profesionales y del ambiente. Los resultados mostraron asociaciones significativas entre la carga de trabajo y la seguridad del paciente. La mejor dotación de personal mostró mejores resultados para el manejo y para el cuidado del paciente. Los principios del pensamiento ecológico y restaurativo contribuyeron a la comprensión de algunos de los aspectos involucrados en esta intricada relación, a partir de las miradas de los profesionales, con un enfoque participativo.

Facilitators and barriers to safe emergency department transitions for community dwelling older people with dementia and their caregivers: a social ecological study.

BACKGROUND: Internationally, older adults visit the ED at a rate higher than other age groups. Little attention has been given to ED care for older people with dementia, although concern for such care is growing with the increasing number of individuals worldwide affected by this significant disabling problem. It is critical to understand ED transitional processes and consequences because the complexity of dementia care poses multiple challenges to optimizing safety, effectiveness and quality of care during admission, assessment, and treatment in this setting. METHOD: Using an interpretive, descriptive exploratory design with three iterative, interrelated phases, we conducted interviews, created a photographic narrative journal (PNJ), and finally held photo elicitation focus groups to identify factors that facilitate or impede safe transitional care for community dwelling older adults with dementia in two Canadian emergency departments, and to identify practice solutions for nurses. We purposively sampled to recruit ten older adult-family caregiver dyads, ten ED RNs, and four Nurse Practitioners. Data were analyzed using constant comparative analysis. RESULTS: Four interconnected reinforcing consequences emerged from our analysis: being under-triaged; waiting and worrying about what was wrong; time pressure with lack of attention to basic needs; and, relationships and interactions leading to feeling ignored, forgotten and unimportant. Together these consequences stem from a triage system that does not recognize atypical presentation of disease and illness. This potentiated a cascade of vulnerability in older people with dementia and their caregivers. Nurses experienced time pressure challenges that impeded their ability to be responsive to basic care needs. CONCLUSIONS: In an aging population where dementia is becoming more prevalent, the unit of care in the ED must include both the older person and their family caregiver. Negative reinforcing consequences can be interrupted when nurses communicate and engage more regularly with the older adult-caregiver dyad to build trust. System changes are also needed to support the ability of nurses to carry out best practices.

An integrative review of infection prevention and control programs for multidrug-resistant organisms in acute care hospitals: a socio-ecological perspective.

BACKGROUND: The infection rates of multidrug-resistant organisms (MDRO) are increasing in Canada and the United States. The prevention and control of MDRO infections remain an important issue in acute care hospitals. Although comprehensive infection prevention and control programs have been recommended, there is little evidence to date of their effectiveness or of what aspects are most important. OBJECTIVES: Our objectives were to review and critique the literature on the relationship between an MDRO infection and control program and MDRO rates in acute care hospitals. METHODS: Studies including original research published between January 1, 1998, and May 14, 2009, were identified through MEDLINE, CINAHL, EMBASE, PUBMED, The Cochrane Library, and expert consultation. A comprehensive search strategy was developed with a librarian to find studies that covered the main subject areas of this integrative review. RESULTS: Of the 1,382 papers retrieved, 47 were reviewed, and 32 studies met the inclusion criteria. The interventions in the included studies were assessed using the tier 1/tier 2 framework. A total of 18 (56.25%) studies had an administrative measure as an intervention; 20 (62.5%) studies had education and training of health care personnel; 8 (25.0%) studies had judicious use of antimicrobial agents; 17 (53.1%) studies used surveillance; 24 (75.0%) studies had infection control precautions to prevent transmission; 7 studies (21.9%) introduced environmental measures; and 9 (28.1%) studies used patient decolonization. Although all the 32 studies were quasiexperimental studies, only 2 (5.9%) studies provided sample size calculations, and only 5 studies reported confounding factors. Whereas 27 used an interrupted time series design and 2 were controlled pre- and post-intervention designs, 3 were pre- and post-intervention without control groups. CONCLUSION: This integrative review demonstrated that the evidence of the relationship between MDRO infection prevention and control programs and the rates of MDRO is weak. Although major methodologic weaknesses exist in the published literature making it not possible to exclude other plausible explanations for the reduction of the acquisition of MDRO, the overall evidence does support the use of multiple interventions to reduce the rates of MDRO in acute care hospitals. Whereas it is unclear which bundles of interventions are effective, there is a clear suggestion that multiple simultaneous interventions can be effective in reducing MDRO infections. In addition, despite the limitations of interrupted time series, multiple studies employing active surveillance cultures were associated with reduced MDRO infections. Future individual reports of outbreaks and intervention studies should be written in a standardized manner using the recommended Outbreak Reports and Intervention Studies of Nosocomial Infection (ORION) guidelines. Further research is needed on the proposed tier 1/tier 2 framework clearly indicating all the interventions implemented.

Nursing Care and Patient Safety: Visualizing Medication Organization, Storage and Distribution with Photographic Research Methods / Cuidados de enfermagem e segurança do paciente: visualizando a organização, acondicionamento e distribuição de medicamentos com método de pesquisa fotográfica / Cuidado de enfermería y seguridad del paciente: visualizando la organización, acondicionamiento y distribución de medicamentos con método de investigación fotográfica

In this qualitative study, we adapted photographic research methods from earlier nursing research to identify factors related to organization, storage and distribution that could lead to errors in the selection, preparation and administration of medications. The research excerpt presented here was developed in a clinical unit of an urban Brazilian public hospital. The research participants were nurses working at that unit and students from the two final semesters of the Undergraduate Nursing Course. We collected digital photographs of the medication system and subsequently used photo elicitation to review the images with research participants, so as to obtain their perceptions and narratives of working with medications in the unit. We report selected findings here on the organization, storage and distribution of medications, which indicate there is room to improve the safety of the medication system.

Neste estudo qualitativo, adaptou-se o método de pesquisa fotográfica de estudos anteriores, para identificar fatores relacionados à organização, acondicionamento e distribuição que poderiam levar a erros na seleção, preparo e administração de medicamentos. O recorte da pesquisa apresentado foi desenvolvido em unidade de clínica médica de um hospital público, Brasil. Os participantes da pesquisa foram enfermeiros que trabalhavam naquela unidade e acadêmicos dos dois últimos semestres do curso de graduação em Enfermagem. Obtiveram-se fotografias digitais do sistema de medicação e, subsequentemente, utilizou-se a elicitação das fotos para rever imagens com os participantes da pesquisa, a fim de obter suas percepções e narrativas a respeito do trabalho com medicamentos, naquela unidade. Apresenta-se uma seleção dos principais achados da pesquisa sobre organização, acondicionamento e distribuição de medicamentos, indicando que há espaço para melhorar a segurança do sistema de medicação.

En este estudio cualitativo, se adoptó el método de investigación fotográfica de estudios anteriores, para identificar factores relacionados a la organización, acondicionamiento y distribución, los que podrían conducir a errores en la selección, preparación y administración de medicamentos. Esta parte de la investigación que se presenta fue desarrollada en una unidad de clínica médica de un Hospital Público, en Brasil. Los participantes de la investigación fueron enfermeros que trabajaban en aquella unidad y estudiantes de los dos últimos semestres del Curso de Graduación en Enfermería. Fueron obtenidas fotografías digitales del sistema de medicación y subsecuentemente, se obtuvieron las fotos para analizar las imágenes con los participantes de la investigación, a fin de obtener sus percepciones y narrativas al respecto del trabajo con medicamentos en aquella unidad. Se presenta una selección de los principales hallazgos de la investigación sobre organización, acondicionamiento y distribución de medicamentos, indicando que hay espacio para mejorar la seguridad del sistema de medicación.

Nursing care and patient safety: visualizing medication organization, storage and distribution with photographic research methods.

In this qualitative study, we adapted photographic research methods from earlier nursing research to identify factors related to organization, storage and distribution that could lead to errors in the selection, preparation and administration of medications. The research excerpt presented here was developed in a clinical unit of an urban Brazilian public hospital. The research participants were nurses working at that unit and students from the two final semesters of the Undergraduate Nursing Course. We collected digital photographs of the medication system and subsequently used photo elicitation to review the images with research participants, so as to obtain their perceptions and narratives of working with medications in the unit. We report selected findings here on the organization, storage and distribution of medications, which indicate there is room to improve the safety of the medication system.

An integrative review of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections.

BACKGROUND: The objectives of this integrative review were to critically examine the overall state of the current evidence on the relationship between hand hygiene interventions and the incidence of health care-associated infections (HCAIs) in acute care and long-term care settings, and offer recommendations for future directions in the field based on our findings. METHODS: We searched for original research and reviews of research published between January 1, 1996, and July 31, 2006. Studies were identified through the electronic databases Medline, CINAHL, EMBASE, PUBMED, the Cochrane Library, and through expert consultation. Our comprehensive search strategy included all English articles for which hand hygiene or handwashing-related terms were combined with HCAIs. All studies that investigated a relationship between hand hygiene practices and HCAIs in acute care facilities were considered. These hand hygiene practices included the initiation of multimodal hand hygiene initiatives, the introduction of alcohol sanitizers, the implementation or changes of the infection control practices or infection control policies, and other organizational interventions. Studies only examining hand hygiene compliance, efficacy of alcohol hand gels, plain soap, and antimicrobial soap in reducing bacteria count recovered from hands were excluded. RESULTS: Of the 1120 articles retrieved, 35 publications, including 4 reviews of research discussed at the outset of this article, met our inclusion criteria. The remaining 31 eligible original studies included 18 (58.07%) before and after studies without control groups, 4 (12.90%) before and after studies with a control group, 3 (9.68%) cohort studies with no control group, 4 (12.90%) cohort studies with a control group, and 2 (6.45%) randomized trials. Over 50% (16 or 31) of the studies were conducted in the U.S. Two independent reviewers conducted independent evaluations of all eligible studies, critiquing and scoring each study using a rating scale for examining the fatal flaws of quasi-experimental and before and after studies. CONCLUSIONS: There is a lack of rigorous evidence linking specific hand hygiene interventions with the prevention of HCAIs. The varied nature of the interventions used and the diverse factors affecting the acquisition of HCAIs make it difficult to show the specific effect of hand hygiene alone. The most frequent methodologies currently used in this research area are before and after observational studies without a control comparison group. Based on these findings, we recommend that researchers used a modified version of Larson's 2005 criteria to guide the design and conduct of future before and after observational studies in this area. We also argue that as we accumulate stronger evidence of which interventions are most effective, we need to develop additional research approaches to study how organizations succeed and fail in fostering the uptake of evidence-based hand hygiene interventions.