Advance care planning for residents in aged care facilities: what is best practice and how can evidence-based guidelines be implemented?

Background Advance care planning in a residential care setting aims to assist residents to make decisions about future healthcare and to improve end-of-life care through medical and care staff knowing and respecting the wishes of the resident. The process enables individuals and others who are important to them, to reflect on what is important to the resident including their beliefs/values and preferences about care when they are dying. This paper describes a project conducted as part of the Joanna Briggs Institute Clinical Aged Care Fellowship Program implemented at the Manningham Centre in metropolitan Melbourne in a unit providing services for 46 low and high care residents. Objectives The objectives of the study were to document implementation of best practice in advance care planning in a residential aged care facility using a cycle of audit, feedback and re-audit cycle audit with a clinical audit software program, the Practical Application of Clinical Evidence System. The evidence-based guidelines found in 'Guidelines for a Palliative Approach in Residential Aged Care' were used to inform the process of clinical practice review and to develop a program to implement advance care planning. Results The pre-implementation audit results showed that advance care planning practice was not based on high level evidence as initial compliance with five audit criteria was 0%. The barriers to implementation that became apparent during the feedback stage included the challenge of creating a culture where advance care planning policy, protocols and guidelines could be implemented, and advance care planning discussions held, by adequately prepared health professionals and carers. Opportunities were made to equip the resident to discuss their wishes with family, friends and healthcare staff. Some residents made the decision to take steps to formally document those wishes and/or appoint a Medical Enduring Power of Attorney to act on behalf of the resident when they are unable to communicate wishes. The post-implementation audit showed a clear improvement as compliance ranged from 15-100% for the five audit criteria. Strong leadership by the project team was effective in engaging staff in this quality improvement program. Conclusion The outcomes of the project were extremely positive and demonstrate a genuine improvement in practice. All audit criteria indicate that the Manningham Centre is now positively working towards improved practice based on the best available evidence. It is hoped that as the expertise developed during this project is shared, other areas of gerontological practice will be similarly improved and more facilities caring for the older person will embrace evidence-based practice.     

Improving and ensuring best practice continence management in residential aged care

Background Continence Management within residential aged care is an every day component of care that requires assessment, implementation of strategies, resource allocation and evaluation. At times the management of incontinence of aged residents can be challenging and unsuccessful. The project chosen through the Clinical Fellowship program was Continence Management with the aim of raising awareness of best practice to assist in improving and providing person-centred resident care. Aims/objectives ? Review the literature on best practice management of incontinence ? Evaluate current practice in continence management for elderly residents within residential aged care services ? Improve adherence to best practice strategies of care for incontinence ? Raise awareness within the nursing home of the best practice management of incontinence ? Promote appropriate and effective use of resources for continence management ? Deliver individualised person-centred care to residents. ? Ensure best practice in continence management Methods The Joanna Briggs Institute (JBI) Practical Application of Clinical Evidence System clinical audit tool was utilised to measure current practice against best practice. The results identify gaps that require improvement. The Getting Research into Practice process then allowed analysis of the level of compliance with each of the audit criteria, which would identify any barriers in implementing a selected course of action and aim to improve compliance. The project team was consulted with additional stakeholder consultation to form an action plan and implement strategies to improve practice. Results Although 100% compliance with all audit criteria in audit 1 and 2 was not achieved, there was improvement in the criteria concerning the documented fluid intake for residents. Further strategies have been identified and implemented and this continues to be a 'work in progress'. Staff now have an acute awareness of what best practice means and the impact their practices have on continence management. The JBI clinical audit and feedback cycle will continue to facilitate the measuring and implementation of best practice for resident outcomes in residential aged care.     

Reducing physical restraint use in residential aged care: implementation of an evidence-based approach to improve practice

Background This paper describes the approach taken by three high care residential facilities in reducing physical restraint use and improving practice when physical restraint is used as a care strategy. At the time of the project these three facilities provided care for 174 residents, with over half of the residents having a diagnosis of dementia. Method A process of audit and feedback was used to identify initial compliance with best practice and facilitate identification of barriers to changing and improving clinical care. Results Gaps were found in the areas of organisational documentation (including policy, procedures, forms and information for residents and their families) and staff education on the topic of physical restraint. Once these gaps were known, the task was to develop strategies to address the needs of three stakeholder groups: individual clinicians, residents and their families, and the organisation as a whole. Conclusion The paper shows the advantages of auditing compliance with evidence-based criteria as a measure of improvements in clinical care, and describes the changes implemented as a means of improving practice and reducing physical restraint use. The results show that the process has been effective in achieving results in the short term, with large increases in the area of staff education, and improvements in the assessment of people identified as possibly requiring restraint. Future plans for sustaining and consolidating change and moving forward with improvements are discussed. The results so far have been encouraging and the organisation is committed to continue to improve compliance with best practice with the vision of eventually achieving restraint-free care environments.     

Reducing and/or minimising physical restraint in a high care, rural aged care facility

Background This report takes you through a journey of implementing evidence-based best practice guidelines in relation to physical restraint in an aged care facility. It describes the processes involved in making changes to an existing system, introducing evidence-based guidelines and collaboratively achieving compliance with best practice. The project formed part of a combined initiative between the Joanna Briggs Institute and the Commonwealth Department of Health and Ageing, called the Aged Care Clinical Fellowship Program. The Joanna Briggs Institute Practical Application of Clinical Evidence System, an online audit-based tool that includes an action research process Getting Research Into Practice was used to facilitate audit data collection and analysis. This report demonstrates that effective clinical leadership and evidence-based research, combined with a strategy of audit, feedback and re-audit, can become an effective change agent to improve clinical practice in residential aged care facilities. Aims/objectives The aims of this project were to increase staff knowledge and awareness of restraints, improve practices in restraint assessment and usage, reduce or minimise the amount and type of restraints used and ensure the least restrictive device possible was utilised in a rural aged care facility. Methods A system of audit, feedback and re-audit was performed using the Joanna Briggs Institute Practical Application of Clinical Evidence System software. This was completed in a series of stages over a period of 6?months. The first stage was to apply defining characteristics to each of the evidence-based audit criteria to determine compliance. A team of staff was set up to assist with the project. An initial audit was conducted, followed by a situational analysis of the findings. From this an action plan for improvement using Getting Research Into Practice was developed. The action plan was then implemented and the criteria re-audited and reviewed. Results The initial audit confirmed non-compliance as expected in two criteria. All criteria showed improvement in the re-audit. Those criteria with the least compliance in the initial audit showed the most improvement in the re-audit. Conclusion Effective change processes can be achieved when there is an identified reason or need for change, and when staff are aware of that need. With clinical leadership and education attitudes, fears and myths can be dispelled and improved performance will come out.     

The experiences of pediatric social workers providing end-of-life care

Pediatric social workers working in acute care hospital settings may care for children and their families in end-of-life circumstances. This qualitative study is part of a larger study focusing on the experiences of health care providers working with dying children. This study consisted of 9 semi-structured interviews of acute care pediatric social workers who work with dying children and their families. Themes included the role of social work with dying children, the impact of their work and coping strategies. Authors suggest a hospital-worker partnership in supporting staff and promotion of supportive resources.     

Managed death in a PACE: pathways in present and advance directives

OBJECTIVES: To test the effect of an innovative method of documenting present and advance health care wishes on the rates of completion and the qualitative choices of health care wishes. DESIGN: Interventional prospective cohort (pre- and post-). SETTING: Program for All-inclusive Care of the Elderly (PACE) site in St. Louis, MO. PARTICIPANTS: Enrolled PACE participants. INTERVENTION: A documentation tool that captures both present and advance directives in a framework of "pathways," blending goals of care with typical procedure-oriented directives. MEASUREMENTS: Data from medical records to calculate rates of health care wishes (HCW) completion, proportions of qualitative choices, and compliance with wishes at death. RESULTS: Baseline prevalences of present directives (PD) and advance directives (AD) were 77% and 36%, respectively, while Do Not Resuscitate (DNR) wishes were documented in 48% of PD and 26% of AD. After implementation of the Pathways Tool, completion rates increased to 99% for both PD and AD. Documented DNR wishes decreased to 38% of PD and increased to 66% of AD. Qualitative choices for care (Longevity vs Function vs Palliation) changed toward a palliation pathway for AD (from 9% to 53%). The rate of dying at home increased from 24% to 65%. Compliance with end-of-life wishes increased from 72% to 96%. These are statistically significant. CONCLUSION: Introduction of a novel pathways method of documenting HCW in a PACE site was associated with increased completion, preferences toward less invasive levels of care at life's end, and increased compliance with participants' wishes and deaths at home. Future research to validate the methodology employed in this intervention should be conducted in other long-term care settings.     

Compliance with best practice: implementing the best available evidence in the use of physical restraint in residential aged care

The Aged Care Clinical Fellowship, funded by the Commonwealth Department of Health and Ageing and conducted through the Joanna Briggs Institute is an initiative designed to improve the care of older Australians through clinical leadership and promotion of best practice. This paper outlines one of the projects undertaken at Carinya of Bicton, a residential aged high care facility, using an audit and feedback process to implement best practice standards in the use of physical restraint. Aims Between 12% and 47% of residents in residential care facilities are restrained; however, initial observation of residents restrained in the project facility showed that restraint devices were utilised in up to 40% of residents. Within the aged care sector there has been a shift in attitude to reducing or eliminating restraint in aged care facilities. Restraint is seen as a negative experience for the resident, being associated with physical discomfort, embarrassment and restriction of freedom and of movement. The purpose of the project was to improve practice in the area of physical restraint through the process of auditing current practice against evidence-based, best practice criteria and ultimately to reduce the level of restraint in the facility. Methods This practice improvement project utilised an audit and implementation cycle. The Joanna Briggs Institute Practical Application of Clinical Evidence System and best practice criteria developed from a systematic review were used to determine compliance with best practice. The Getting Research into Practice module was then employed to develop strategies to improve practice. Results The follow-up audit indicated there has been a reduction in the number of residents restrained, increased use of alternatives to restraint and an awareness on the part of all care staff of the policies and procedures, which govern the use of restraint in the facility. Conclusions It is recognised that the success of this project is in part due to the focus of all staff in the area and the support and assistance given to staff by management and the project team. This support will need to continue because while practice has improved in the short term, there are still barriers to change in this area. Also of benefit has been a shift in emphasis of the continuous quality improvement program at the facility to a more clinical focus. Management and staff, especially members of the project team have agreed that this process be utilised to improve practice in a number of other areas such as falls, constipation and behaviour management.     

Living and dying: responsibility for end‐of‐life care in care homes without on‐site nursing provision ‐ a prospective study

The aim of the study was to describe the expectations and experiences of end‐of‐life care of older people resident in care homes, and how care home staff and the healthcare practitioners who visited the care home interpreted their role. A mixed‐method design was used. The everyday experience of 121 residents from six care homes in the East of England were tracked; 63 residents, 30 care home staff with assorted roles and 19 National Health Service staff from different disciplines were interviewed. The review of care home notes demonstrated that residents had a wide range of healthcare problems. Length of time in the care homes, functional ability or episodes of ill‐health were not necessarily meaningful indicators to staff that a resident was about to die. General Practitioner and district nursing services provided a frequent but episodic service to individual residents. There were two recurring themes that affected how staff engaged with the process of advance care planning with residents; ‘talking about dying’ and ‘integrating living and dying’. All participants stated that they were committed to providing end‐of‐life care and supporting residents to die in the care home, if wanted. However, the process was complicated by an ongoing lack of clarity about roles and responsibilities in providing end‐of‐life care, doubts from care home and primary healthcare staff about their capacity to work together when residents’ trajectories to death were unclear. The findings suggest that to support this population, there is a need for a pattern of working between health and care staff that can encourage review and discussion between multiple participants over sustained periods of time.     

A survey of end-of-life care in care homes: issues of definition and practice

Care homes throughout the UK provide long-term care for frail older people. Whilst care homes are a home for life, many of the older people living in this setting also die there. There is increased interest in improving the care that older people receive in care homes towards the end of life. One way to achieve this has been through links with specialist palliative care services. The knowledge held in care homes by staff, residents and their family carers has yet to be fully integrated into this work. Consequently, a postal survey of care home managers in one English county was undertaken to examine the characteristics of end-of-life care for older people in these care homes. We sought to establish the managers' understanding of end-of-life care; the extent to which dying and death is present in this setting; the attributes of the resident population living in these care homes; and the availability of resources to support the provision of end-of-life care in this setting. The survey identified that managers held diverse understandings regarding the meaning of end-of-life care. The features of the residents' conditions and the dying that they experience requires a different way to conceptualise end-of-life care. A longer-term perspective is offered here that encompasses the whole period of a person's residence in a care home.     

Evaluation of an educational program for long-term care nursing assistants

OBJECTIVES: To determine if an educational program can improve knowledge and attitude among ancillary staff on end-of-life care issues in a long-term care facility. DESIGN: A pilot study using a pre- and post-test design prior to and at the completion of an education intervention. SETTING: A long-term care facility in suburban Philadelphia that has 150 assisted living beds and 53 nursing home beds. PARTICIPANTS: Long-term care ancillary staff including certified nursing assistants (called "care managers" at this facility), social workers, recreational therapists, and food service workers. INTERVENTION: The intervention was a novel educational program consisting of five in-service lectures with accompanying take home self-study modules for ancillary staff in long-term care entitled "Dignity in Dementia." MEASUREMENTS: Ancillary staff attitudes and knowledge on end-of-life issues in dementia were assessed with a knowledge and attitude questionnaire pre- and post-intervention. One-year follow-up questionnaires were administered to assess long-term maintenance of knowledge and attitude changes. RESULTS: Thirty-two ancillary staff completed the pre-intervention questionnaires. Twenty-nine ancillary staff completed the post-intervention questionnaires (90.6%). There was a significant change in the end-of-life knowledge level of the ancillary staff (P =.0270). Specifically, there was a significant change in one question dealing with dementia as a terminal disease (P = .006). There were also significant changes in the average attitude scores of the ancillary staff. (P = .0242). One-year follow-up revealed that both knowledge and attitude changes were maintained. CONCLUSIONS: This pilot project demonstrates that a staff educational program on end-of-life care for dementia residents can improve end-of-life knowledge and attitudes among long-term care ancillary staff and that this improvement can be maintained for up to 1 year. This intervention is easily reproducible in the long-term care setting. This project is an important step in helping improve end-of-life care for dementia residents in long-term care settings by improving the knowledge and attitudes of their caregivers.     

An evaluation of the implementation of a best practice guideline on tracheal suctioning in intensive care units

Aim To minimise suctioning-induced complications in intensive care patients, it is crucial that nurses are able to perform the procedure safely and act in accord with research-based recommendations. This paper reports the process of developing, disseminating and implementing the best practice guideline and an evaluation of the process and outcomes of care during and following its implementation in intensive care units. Methods The study was divided into four phases: (i) to develop the best practice guideline and plan strategies for its dissemination and implementation; (ii) to audit the current practice of nurses in the tracheal suctioning of patients in intensive care units with an artificial airway; (iii) to disseminate and implement the best practice guideline; and (iv) to evaluate the process as well as outcome of care following its implementation in intensive care units. Results The pretest results indicate that gaps exist between actual nursing practice and recommendations based on research evidence. Most nurses performed the skills in accord with the best practice guideline, with 65% nurses scoring above the 70% level. The post-test audit results show that, overall, nurses demonstrated a good endotracheal suctioning technique, with 96% scoring above 75%, indicating an overall improvement in compliance with the guideline. A statistically significant difference was found between the pretest (73%) and post-test (89%) compliance scores (t?=?-7.67, P?相似文献   

Care for the terminally ill: a life-affirming paradigm

By incorporating the core values of end-of-life patients and their families into care decisions, providers can offer compassionate care for the dying and avoid unnecessary and futile efforts that not only increase health care costs but often violate the spiritual, emotional, and cultural needs and wishes of the patients and their families.     

Three factors critical for end-of-life care

Appropriate care of persons with life-threatening illnesses requires a different, perhaps higher level of response from organized healthcare than has been typical in the past. This involves three critical components: Leaders must be committed, visible advocates of high-quality end-of-life care. This enables them to plan changes, deploy resources, and integrate this commitment throughout the organization's strategic plan. Ensuring appropriate care of the dying requires adequate human and financial resources. First, the organization must fully identify the educational and service needs of patients, families, and care givers experiencing life-threatening illnesses. The organization must work well with other community-based organizations to address identified needs. Senior managers can improve care by personally commissioning teams, acknowledging success, and rewarding performance. Finally, organizational goals, strategies, and performance objectives must be shaped by a commitment to ensure appropriate care of the dying. Our commitment to the dying must be based on our values. An organizational "statement of rights and responsibilities" is one way of providing a visible expression of the mission, core values, and mutual responsibilities among care givers and patients, residents, HMO members, and clients.     

Staff perceptions of end-of-life care in long-term care

OBJECTIVE: Although residential care/assisted living facilities and nursing homes have increasingly become a significant site of death for older Americans, little is known about staff perceptions of end-of-life care, perceived need for improvement in care, and differences by type of setting. DESIGN, SETTING, AND PARTICIPANTS: Ninety-nine staff provided their perceptions of end-of-life care for 99 decedents from 74 residential care/assisted living facilities and nursing homes in four states as part of a larger cohort study. Staff were interviewed retrospectively regarding care provided during residents' last month of life. MEASUREMENTS: Staff reported on 11 areas of end-of-life care, describing the importance of each area and the level of improvement they felt was indicated. Weighted "need for change" scores were calculated as the product of perceived importance and need for improvement. RESULTS: Both residential care/assisted living and nursing home staff reported a need for more staff education and nursing assistant time, as well as more use of volunteers. The two lowest ranked items for both facility types were involvement of hospice and encouragement for staff to attend funeral services. Nursing home staff perceived a greater need for improvement than residential care/assisted living staff in all 11 areas. CONCLUSION: Results underscore the staffing demands of end-of-life care across facility types, and staff desires to be able to provide quality care throughout the dying process.     

End-of-life experiences and the dying process in a Gloucestershire nursing home as reported by nurses and care assistants

This article presents an interim study into the end-of-life experiences of elderly residents in a Gloucestershire nursing home as reported by nurses and care assistants. It draws comparisons between the experiences of an end-of-life experiences pilot study conducted with the Camden Palliative Care Team in the United Kingdom with those of the nursing home staff to consider whether the dying experience of elderly nursing home residents is the same as those whose lives are foreshortened through terminal illness. It draws the conclusion that elderly residents have end-of-life experiences similar to those described in the Camden pilot study. It also examines the effect that end-of-life experiences have on the carers and reflects on possible needs for specialized training and support to deal with such existential issues.     

Correct placement of blood pressure cuff during blood pressure measurement

Aim The aim of this project was to educate staff nurses and enrolled nurses on the correct placement of blood pressure cuff and monitor the compliance of best practice to audit criteria. Methods This project adopted a pre- and post-implementation audit approach. It utilised the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programs. The project utilised three audit criteria that are considered the best practice standards. The audit took place in a 10-bed oncology high-dependency unit that involved 24 nurses. Result The post-implementation audit findings revealed an improvement in all the three criteria. The first criterion scored 100% consistent documentation of blood pressure measurement in the clinical charts by the nurses. The second criterion showed a 50% improvement in the correct placement of blood pressure cuff on the arm circumference. The third criterion achieved a 12% improvement in compliance with maintaining the patient's arm at the heart level. Conclusion This project highlighted some essential strategies that are required to implement evidence in clinical practice. These strategies include planning a systematic process, using Joanna Briggs Institute best practice sheet, involving relevant stakeholders and using multifaceted strategies. Having a committed and enthusiastic team contributed to the positive outcomes. The challenge now is to develop strategies in sustaining the momentum of compliance and embed the new evidence into routine clinical practice.     

Symptom experiences of residents dying in assisted living

OBJECTIVES: To identify the end-of-life symptom experiences of residents who died in assisted living, to describe family satisfaction with the end-of-life care, and to compare end-of-life symptom distress across 4 settings: assisted living, private home, nursing home, and hospital. DESIGN: In-person interviews with family members of people aged 65 or older who had died 2 to 4 months earlier in an assisted-living facility. Symptom distress reports were compared with data from prior studies in other settings. SETTING: A mixed urban-rural community in the Northwest. PARTICIPANTS: Twenty-five family members who self-identified as closely involved in the care or decision making for a relative who died in an assisted-living facility. MEASUREMENTS: A 28-item interview guide composed of demographic questions, the modified Family Memorial Symptom Assessment Scale-Global Distress Index (FMSAS-GDI), and open-ended items describing the decedent's last days and family satisfaction with care and symptom management. RESULTS: Symptoms experienced by at least 75% of decedents were lack of energy, loss of appetite, dry mouth, drowsiness, and pain. Symptom experiences in assisted living were comparable to those in other settings. Families overall were satisfied with end-of-life care in assisted living, but had concerns about communication among providers, inadequate monitoring of their decedent, and lack of staff knowledge specific to symptom management. CONCLUSION: Residents dying in assisted-living settings have similar symptom distress experiences as people dying in other, more studied settings. As residents and families alike overwhelmingly support resident deaths in their assisted living "home," policies, structures, and processes are needed to ensure that end-of-life care needs are met.     

End-of-life care: improving quality of life at the end of life

PURPOSE/OBJECTIVES: The purpose of this article is to identify barriers and interventions that influence quality of life at the end of life. PRIMARY PRACTICE SETTINGS(S): Primary care, acute inpatient care, case management, and end-of-life care settings. FINDINGS/CONCLUSION: Death and dying affects the whole family, not just the individual who is dying. Early identification and recognition of end-of-life care choices heavily influence the quality of life an individual experiences during the dying process. Unfortunately, delaying end-of-life care plans is common. Over the years, the social structure and family structure have changed leaving many patients and families searching for viable end-of-life care options. Advancements in technology have affected the way medical professionals approach the end of life making a difficult decision for patients and families even more difficult by offering medical interventions that may not be necessary. To steer end-of-life care toward evidence-based practice standards, there needs to be additional research on the effectiveness of the various types of care available. Because case managers are often on the front lines of communicating and arranging end-of-life care, case managers need a clearer understanding of end-of-life care choices and how to communicate these choices to patients and families. The hospice and palliative care movements have been instrumental in increasing the understanding of end-of-life care and in providing patients alternatives to dying in the hospital. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: * Only 25% of patients eligible for hospice actually enter hospice programs.* The average time spent in hospice is 3 weeks.* The most significant barrier in coordinating and providing end-of-life care is inadequate communication.* Early discussion of prognosis and end-of-life care options helps facilitate earlier entry into hospice and palliative care programs.* The nursing profession needs additional research to determine the effectiveness of the various types of end-of-life care available and steer end-of-life care toward evidence-based practice standards.     

Survey on death and dying in Hong Kong: attitudes, beliefs, and preferred end-of-life care

Social Workers in end-of-life and palliative care have a particular opportunity to ease the dying process by providing culturally appropriate services to the dying and their families. In today's multicultural social environment, with an ever-increasing immigrant population, social workers are challenged to be knowledgeable about diverse cultures. Recently, a forum of health care professionals and social workers in Hong Kong conducted a survey of the general population to assess death and dying attitudes, beliefs, and preferences for end-of-life care. Four-hundred-thirty Hong Kong Chinese participated in a telephone interview. Responses were compared by gender. The survey results not only contribute to an understanding of Hong Kong Chinese, but can inform social workers who practice with Chinese immigrants to the United States.     

Enhancing hand hygiene in a polyclinic in Singapore

Aims This project intended to enhance the compliance rate of nurses (registered nurses and enrolled nurses) in a polyclinic to the five moments of hand hygiene. It proposed to conduct a preliminary baseline audit on the standard of hand hygiene practice, educate nurses on the five moments of hand hygiene in the polyclinic and conduct a post-implementation audit to capture the compliance rate of nurses on practising the five moments of hand hygiene. Methods The team conducted a pre- and post-implementation audit using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice programme, from July 2011 through November 2011, over a period of 5?months. The pre-implementation audit, which involved 23 nurses from a polyclinic in Singapore, also adopted five out of the seven criteria suggested by the Joanna Briggs Institute. The intervention composed of educating the nurses on the five moments of hand hygiene, providing guidance to nurses in a non-intimidating manner, adopting an open communication approach and the appropriate placement of alcohol-based hand rub at the point of care in the service rooms. Results The post-implementation audit results showed significant improvement in four of the five criteria, with the greatest improvement observed for criterion 2: 'Hands are decontaminated immediately before each and every episode of direct patient contact or care, and/or all inanimate objects, including equipment'. Conclusion This study has proven that by conducting the pre- and post-implementation audit using the five criteria gathered from the Joanna Briggs Institute Practical Application of Clinical Evidence System, nurses' hand hygiene compliance can be enhanced. From this study, we could also conclude that nurses' knowledge and accessibility/suitability of alcohol-based hand rubs play an important role in achieving better hand hygiene practices. Positive results were seen even though the project was conducted within a short period. Contributing factors could be attributed to efforts by researchers in identifying barriers for compliance from the ground and addressing them in the intervention phase. In addition, the relentless enthusiasm and commitment of stakeholders, team members and nurses had also contributed to the success of this study. This project was the first to report an improvement in the hand hygiene compliance of primary healthcare nurses in Singapore.