Understanding the concept of infection control is an essential part of a nursing student's education. The Centers for Disease Control and Prevention (CDC) estimates that each year approximately 2 million patients admitted to acute-care facilities in the United States acquired infections that were not related to the condition for which they were admitted.1 The overall annual medical cost of hospital-acquired infections (HAIs) to US hospitals ranges from $28.4 billion to $33.8 billion.2 The CDC estimates that infections contribute to 99,000 associated deaths each year. Five percent to 10% of hospitalized patients annually acquire HAIs, which adds nearly $20 billion to healthcare costs each year.3 In 2002, CDC hand hygiene guidelines were released, noting that the use of hand hygiene significantly decreases the rates of healthcare associated-infections.4

An essential part of every nursing course, infection control practices are continuously reinforced throughout the curriculum. Recognizing the ongoing problem of noncompliance with hand-washing practice, nursing faculty approached infection control staff in our clinical affiliates to see what role our nursing students could play in helping reduce negative outcomes, related to noncompliance with hand-washing policy. With an unexpected enthusiastic response from staff, meetings were arranged with one initial clinical agency to discuss institutional and academia needs and objectives.

The hospital's infection control nurse manager noted the Joint Commission's requirement for healthcare delivery facilities to perform direct observation of staff hand-washing practices and described an ongoing hospital surveillance project, where various healthcare providers were designated as observers for the day, and given the title of "hand-washing ambassador." Direct observation is labor-intensive; however, it provides a means of determining appropriate adherence to practice guidelines and need for reeducation. Observation can enable managers to compare compliance across patient care areas.5 The infection control nurse manager explained that the availability of staff to perform this function was an obstacle to implementation and believed that students could be educated to adequately execute the required infection control surveillance of employee hand-washing practices. Involvement of students in reminding staff to wash their hands has been shown to increase compliance.6 In addition to observing practice, the students would also be responsible for providing best practice information to any healthcare provider observed practicing incorrect skills. This approach, while enforcing comprehension of infection control, also instilled another important principle of advocacy.

To prepare students prior to participation, students attend infection control lecture, pass a return hand-washing skill demonstration, conduct independent literature searches related to hand-washing and infection control, and view the CDC Web site guideline on hand hygiene (http://cdc.gov/Handhygiene/). After initial training, 2 students are assigned on their clinical day to be hand-washing ambassadors.

On the day of observation, students meet with the director of infection control who questions them about their knowledge and orients them to the forms to be filled out during their observation. Many institutional leaders now empower the bedside nurse to halt a procedure if infection control measures are violated.7 In the present, initiative students wear laboratory coats so they are not identified as students and are empowered by the knowledge that they are actively participating in breaking the chain of infection and ensuring evidence-based practice. After being introduced to the unit's nurse manager, the students maintain a discreet presence outside the patient's room where they can view hand washing. The observer should aim to avoid excessive observation bias by not being too obvious, while not deceiving the observed healthcare worker about the purpose of observation.8 The student ambassadors identify the staff member by their role, for example, nurse, physician, or transporter, and use a simple checklist to document observed hand-washing behavior before and after contact with the patient or patient care items. The students then quietly approach any noncompliant staff as they leave the patient room. They refer to the hospital policy and reinforce the correct steps regarding proper hand hygiene practices. After observing staff in one unit for about an hour, they move on to a second unit and continue the process.

Discussion of Outcomes

After completing their observational experience, student ambassadors meet with their clinical instructor and infection control. The importance of the experience is discussed, and obstacles are explored. Pertinent comments from students include feelings of intimidation and frustration because of lack of compliance by some professionals: "I did approach one doctor; he seemed disturbed by my drawing his attention to coming in contact with what seemed to be a critical patient and not washing his hands. I explained hospital guidelines and he just walked away." This frustration led to more discussion with infection control regarding noncompliance. Although the students are instructed not to be confrontational, they are assured that infection control is everyone's responsibility and that their role in observation is important. Each month, department heads are contacted by the director of infection control to reeducate their staff on hospital policy and the role of hand-washing ambassadors in relation to patient safety. After the initial experience, the infection control department was anxious to set up an immediate rotation for ongoing student participation in infection control activities, and this led to a faculty plan for clinical assignment revision that would involve all second-semester students in various clinical agencies.

Future Considerations

Evidence suggests that the value that nursing students place on hand hygiene declines from the first to the third year of training, probably as a result of their clinical experiences, so it is crucial that the infection control message is reinforced throughout their 3 years.9 As a result of this pilot project, we are seeking more collaborative practice projects, which will better use the valuable resource of student nurses to significantly contribute to healthcare improvement initiatives.

It is important to further evaluate the impact of our clinical initiative on actual practice and infection control rates. Will the proposed model affect the daily practices of healthcare providers on a long-term basis? Will this practice decrease overall infection rates in the participating clinical agencies? Current evidence points to the need for continued observation and collaboration. Institutional follow-up stresses the importance of receiving adequate education on when and how to perform hand hygiene. All healthcare professionals must look to evidence-based guidelines to prevent healthcare-associated infections.10 Other sources have suggested that hospitals could save upward of l0,000 lives annually if they imposed a zero-tolerance policy for workers failing to wash their hands.11 Future collaboration between academia and the healthcare institution will identify if the observed floors had a decrease in infection rates and if the infection control knowledge and practices of students were strengthened. Several infection control departments of clinical affiliates have been contacted about student participation and ongoing projects, and all have voiced a strong interest in participating in collaborative practice.

Conclusion

The collaborative practice of infection control departments and schools of nursing is an excellent model for healthcare reform. In this arena of decreasing healthcare funding, it is imperative that we seek to improve patient care and patient care outcomes using available resources. Students benefit from active learning in the role as teacher and observer as it reinforces critical concepts necessary for safe practice. The institution benefits by potentially lower infection rates, shorter patients hospitalization, and increased compliance with the Joint Commission standards. Organizations that make infection control part of their competency assessment program also demonstrate a commitment to improving patient safety by reducing infections.10 Last, it is hoped that the nursing programs will be viewed as valuable partners in achieving the goal of improving patient care and that finally students will incorporate safe practices to prevent infections from the very outset of their career.

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