Table of Contents
Type: Research Proposal | Subject: Nursing | Level: Masters | Word Count: ~2,500 words
This model research proposal was produced by an Essays UK specialist as reference material for learning purposes only. For support in this field, see our nursing dissertation specialists.
Prepare a research proposal (2,500 words) for an MSc Nursing dissertation investigating a multimodal intervention to improve hand hygiene compliance among nursing staff on acute adult wards. The proposal should include a clear aim and objectives, a concise literature context, a justified methodology, an ethics statement, a project timeline, and an account of the study’s expected contribution.
Healthcare-associated infections (HCAIs) remain one of the most persistent patient safety challenges facing acute hospital care, affecting a substantial proportion of admitted patients and imposing significant costs on already stretched NHS budgets each year (World Health Organization, 2009). Hand hygiene is widely regarded as the single most effective and least costly infection prevention and control (IPC) measure available to ward staff, capable of interrupting the transmission of pathogens between patients, staff and the clinical environment when performed consistently and at the correct moments (Pittet et al., 2000).
The World Health Organization’s “My Five Moments for Hand Hygiene” framework, developed by Sax et al. (2007), provides the internationally recognised structure against which compliance is now measured: before patient contact, before an aseptic task, after body fluid exposure risk, after patient contact, and after contact with patient surroundings. Despite this clear framework and decades of promotional campaigns, observed compliance among nursing staff consistently falls short of local and national targets. A systematic review by Erasmus et al. (2010) found average observed compliance across acute settings of only around forty per cent, with compliance typically lowest before, rather than after, patient contact, precisely the moments most protective of the patient rather than the member of staff.
Beyond the immediate clinical risk, hand hygiene is also recognised as an unusually cost-effective infection prevention measure. Unlike environmental or estates-based interventions requiring substantial capital investment, improving hand hygiene relies primarily on staff behaviour, low-cost point-of-care products and organisational commitment, meaning even a modest, sustained improvement in ward-level compliance represents a comparatively inexpensive route to reduced patient harm (World Health Organization, 2009). This strengthens the practical, as well as the clinical, rationale for the present proposal at a time of considerable financial pressure across NHS acute trusts.
This proposal is grounded in a specific local concern. A recent internal IPC audit on two acute adult medical wards at the proposing student’s placement trust recorded observed hand hygiene compliance of approximately fifty-eight per cent against a trust target of ninety per cent, a gap consistent with the wider literature but one that has prompted local IPC leads to request a structured, evaluable improvement intervention rather than a further round of generic reminder posters. This local shortfall has persisted despite sustained registered nurse vacancy rates and above-average reliance on temporary staff on both wards, a context the ward matron and IPC lead nurse independently identified during scoping discussions as a plausible contributor to inconsistent practice. NICE (2014) quality standard QS61 explicitly identifies hand hygiene compliance monitoring and staff feedback as a core component of an effective IPC programme, yet Gould et al. (2017), in a Cochrane review of hand hygiene interventions, concluded that while multimodal strategies combining education, reminders, feedback and administrative support tend to outperform single-component interventions, the evidence base for which specific combination is most effective in the acute ward setting remains limited and highly context-dependent.
This proposal responds directly to that evidence gap by designing and evaluating a multimodal hand hygiene intervention tailored to the two study wards, combining staff education, environmental prompts and structured audit-and-feedback, and by exploring the barriers and facilitators nursing staff themselves report experiencing in practice.
Framed using a Population–Intervention–Comparison–Outcome (PICO) structure common in applied nursing research, the aim, objectives and questions below translate this local audit concern into an evaluable Master’s-level study.
Aim. To evaluate the effectiveness of a multimodal hand hygiene improvement intervention in increasing hand hygiene compliance, measured against the WHO Five Moments framework, among nursing staff on two acute adult wards.
Objectives:
Research Questions:
The evidence base for hand hygiene improvement is dominated by the seminal Geneva study of Pittet et al. (2000), which demonstrated that a hospital-wide multimodal programme, combining bedside alcohol-based handrub, staff education, performance feedback and institutional commitment, more than doubled observed compliance over several years and was associated with a corresponding fall in HCAI rates. This study established multimodal, rather than single-component, intervention as the standard against which later work is judged, a position later formalised in the WHO’s own multimodal improvement strategy (World Health Organization, 2009).
Erasmus et al.’s (2010) systematic review of thirty-four compliance studies confirmed that average observed compliance remains stubbornly below recommended levels across most acute settings, and identified workload, understaffing and the perceived low personal infection risk associated with certain moments, particularly before patient contact, as recurring explanatory factors rather than simple knowledge deficits. This point is echoed by Squires et al. (2013), who applied behavioural theory to physician hand hygiene and found that interventions targeting automatic habitual behaviour, rather than knowledge alone, produced more durable compliance gains, a finding this proposal’s education-plus-feedback design is intended to draw on.
A useful theoretical explanation for why habit-focused interventions tend to outperform education-only campaigns is offered by Michie, van Stralen and West’s (2011) Behaviour Change Wheel, which frames a target behaviour as a function of Capability, Opportunity and Motivation (the COM-B model). Applied here, staff may already possess the technical knowledge to perform correct hand hygiene (capability) yet still fail to do so consistently if handrub is not readily accessible at the point of care (opportunity), or if the automatic habit of performing the behaviour at each of the five moments has not yet been established (motivation). This framework offers a coherent rationale for combining education, environmental prompts and repeated feedback within a single intervention, rather than treating non-compliance as a simple knowledge deficit.
Gould et al.’s (2017) Cochrane review, updating earlier work, found moderate-certainty evidence that multimodal interventions incorporating goal-setting, reward, and accountability produce a meaningful, if often modest, improvement in compliance, but the review authors explicitly cautioned that most included studies were of relatively short duration and rarely reported whether gains were sustained beyond the immediate post-intervention observation period, a limitation this proposal addresses by including an eight-week post-intervention observation window rather than a single point-in-time re-audit. Loveday et al.’s (2014) epic3 national guidelines similarly identify audit and structured feedback as core elements of an effective IPC programme in NHS hospitals, but note that feedback is often delivered too infrequently or too generically to influence individual practice meaningfully.
A further methodological issue relevant to this proposal concerns the observation method itself. Direct observation, the audit gold standard, is vulnerable to the Hawthorne effect, whereby staff modify their behaviour because they know they are being watched, potentially inflating measured compliance relative to true unobserved practice (Chen et al., 2011). This proposal mitigates this risk, without eliminating it entirely, by using trained IPC link nurses who are already a familiar ward presence, and by extending the observation period so that any short-term reactivity is less likely to dominate the overall compliance estimate.
Taken together, this body of literature points toward four design implications for the present proposal. Interventions should combine at least an educational and a feedback component rather than relying on either alone; the intervention should be designed to target capability, opportunity and motivation together, consistent with the COM-B model, rather than assuming knowledge transfer alone will change habitual behaviour; any evaluation should extend observation beyond the immediate post-intervention window to capture whether gains are sustained rather than merely reactive; and qualitative exploration of staff-perceived barriers should accompany quantitative compliance measurement, since workload and environmental constraints identified by Erasmus et al. (2010) are unlikely to be fully addressed by education alone. These four implications directly shape the methodology set out below.
Design. The study will adopt a quasi-experimental pre-post design across two comparable acute adult medical wards within the same trust, with one ward receiving the full multimodal intervention and the second continuing with standard IPC practice as a non-equivalent comparison ward, an approach consistent with pragmatic quality-improvement research where full randomisation is not operationally feasible (Squires et al., 2013). A ward-level, rather than individually randomised, comparison was chosen because randomising staff within a single ward is not operationally feasible once prompts and feedback are displayed ward-wide, and would risk contaminating the comparison ward’s practice. A short qualitative strand using focus groups will run alongside the quantitative observation to explore staff perspectives on the intervention.
Sample and Participants. All registered nurses and healthcare assistants working substantive shifts on the two study wards, approximately forty-five staff in total, will be eligible for inclusion in the observational compliance audits, which record hand hygiene moments rather than identifiable individual performance. From this pool, staff will be invited to volunteer for one of two focus groups of six to eight participants each, purposively sampled to include a mix of registered nurses, healthcare assistants and shift lengths of service. The target of at least two hundred observed hand hygiene moments per ward follows established UK IPC audit convention (Loveday et al., 2014) and was cross-checked against a two-proportion power calculation: assuming a baseline compliance of fifty-eight per cent and seeking to detect a fifteen-percentage-point increase, a chi-square comparison with alpha at .05 and power at eighty per cent requires a minimum of approximately one hundred and sixty moments per group, confirming the planned sample is adequately powered.
Data Collection. Hand hygiene compliance will be measured using the validated WHO Five Moments direct observation tool (Sax et al., 2007), applied by trained IPC link nurses during unannounced ward rounds. Baseline observation will run for two weeks prior to the intervention, targeting a minimum of two hundred observed hand hygiene moments per ward to provide an adequately powered baseline estimate, followed by an identical two-week post-intervention observation period beginning six weeks after intervention launch to allow the education and prompt elements to embed into routine practice. The intervention itself will comprise a thirty-minute mandatory education session covering the Five Moments framework and local audit findings, laminated point-of-care prompts positioned at each bed space and the ward entrance, and weekly anonymised compliance feedback displayed on the ward’s IPC noticeboard. Focus groups, lasting approximately forty-five minutes, will be conducted after the post-intervention observation period using a topic guide exploring perceived barriers, facilitators and the acceptability of the intervention components. Direct observation was chosen over staff self-report because self-reported compliance has repeatedly been shown to overstate actual practice; Jenner et al. (2006), comparing self-reported against covertly observed hand hygiene behaviour, found self-report considerably exceeded observed compliance, a bias this proposal avoids through exclusive reliance on third-party observation. To protect data reliability, the two trained observers will each independently rate a shared sample of thirty hand hygiene moments during the pilot week, with inter-rater agreement calculated using Cohen’s kappa and a minimum threshold of 0.75 required before independent data collection begins.
Analysis Approach. Pre- and post-intervention compliance proportions on the intervention ward will be compared using a chi-square test of association, with the comparison ward’s pre-post change analysed identically to assess whether any secular trend unrelated to the intervention is present. Effect size will be reported using the phi coefficient alongside the raw percentage-point change. Focus group transcripts will be analysed using Braun and Clarke’s (2006) six-phase thematic analysis, with two researchers independently coding an initial transcript to agree a coding framework before proceeding to full analysis, in order to enhance credibility. All quantitative analysis will be conducted in IBM SPSS Statistics, with significance set at p < .05 and phi effect sizes interpreted against conventional small, medium and large benchmarks to support clinical as well as statistical interpretation of any change detected.
Ethics. As the study involves staff practice observation and anonymised ward-level data rather than patient-identifiable information, it will be submitted to the trust’s Research and Development office for sponsorship and health-research classification advice, following the Health Research Authority’s (2023) UK Policy Framework for Health and Social Care Research, and to the university’s own ethics committee for approval prior to any data collection. Staff participation in focus groups will be entirely voluntary and based on written informed consent, with a clear right to withdraw. Observational audit data will not record individual staff identity, only role and shift, in keeping with standard local IPC audit practice, and all data handling will follow the Nursing and Midwifery Council’s (2018) Code and trust information governance policy. All data will be stored on the university’s secure, encrypted research drive in accordance with UK GDPR and the trust’s Caldicott principles, accessible only to the research team. Focus group recordings will be transcribed by the researcher personally and anonymised using participant codes at the point of transcription, and summary findings will be fed back to both ward teams and the trust’s IPC committee.
Limitations. The non-randomised, single-trust design limits generalisability of any observed effect to other clinical settings, and the use of a non-equivalent rather than randomised comparison ward means secular trends cannot be fully excluded as an alternative explanation for any change observed. The known Hawthorne effect associated with direct observation is a further acknowledged limitation, mitigated but not eliminated by the measures described above. A further limitation is that the qualitative sample relies on staff volunteering for a focus group, which may over-represent colleagues already engaged with IPC practice relative to more sceptical or disengaged staff. Finally, the eight-week window between baseline and post-intervention observation, while longer than many published evaluations, remains too short to establish whether any improvement in compliance would be sustained over a full year, a question left for a future, longer-term follow-up audit beyond the scope of this dissertation.
The project is planned to run across nine months from ethics and trust R&D approval to submission, summarised in Table 1. A two-week gap is built in after the intervention launch before post-intervention observation begins, allowing the new practices to embed on the ward before compliance is re-measured.
| Phase | Activity | Month(s) |
|---|---|---|
| 1 | Ethics approval and trust R&D sponsorship | Month 1 |
| 2 | Link nurse observer training and tool piloting | Month 2 |
| 3 | Baseline compliance observation (both wards) | Month 3 |
| 4 | Intervention design, education sessions and prompt installation | Month 4 |
| 5 | Intervention embedding period | Month 5 |
| 6 | Post-intervention observation and focus groups | Month 6 |
| 7 | Quantitative and thematic analysis | Month 7–8 |
| 8 | Write-up and dissemination to ward teams | Month 9 |
This study will make three practical contributions to local and wider IPC practice. First, it will provide the study wards with a robust, ward-specific evaluation of whether a tailored multimodal intervention, rather than a generic trust-wide campaign, produces a measurable improvement in compliance, directly informing whether the approach should be extended to other wards within the trust.
Second, by combining observational compliance data with staff-reported barriers and facilitators, the study will help distinguish between compliance gaps driven by workload and environmental constraints and those driven by attitudes or habitual behaviour, a distinction the literature identifies as important but which local audit data alone rarely captures (Squires et al., 2013). This has direct relevance for how future IPC education is targeted and resourced.
Third, at a broader level, the study addresses Gould et al.’s (2017) call for hand hygiene intervention research that reports change over a meaningful post-intervention window rather than an immediate re-audit, contributing modest but methodologically considered evidence to a literature that remains surprisingly thin on which specific multimodal combinations sustain compliance gains in the UK acute ward context, and offering a replicable local evaluation model that ward-based IPC link nurse teams elsewhere could reasonably adapt.
Finally, conducting this evaluation will strengthen the researcher’s own competence in applied quality-improvement methodology, a capability expected of Master’s-level nursing graduates working in advanced or leadership roles, with the dissemination plan described above ensuring this translates into a practice-facing output for the host trust rather than remaining a purely academic exercise.
Braun, V. and Clarke, V. (2006) ‘Using thematic analysis in psychology’, Qualitative Research in Psychology, 3(2), pp. 77–101.
Chen, Y.C., Sheng, W.H., Wang, J.T., Chang, S.C., Lin, H.C., Tien, K.L., Hsu, L.Y. and Tsai, K.S. (2011) ‘Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections’, PLoS ONE, 6(11), e27163.
Erasmus, V., Daha, T.J., Brug, H., Richardus, J.H., Behrendt, M.D., Vos, M.C. and van Beeck, E.F. (2010) ‘Systematic review of studies on compliance with hand hygiene guidelines in hospital care’, Infection Control & Hospital Epidemiology, 31(3), pp. 283–294.
Gould, D.J., Moralejo, D., Drey, N. and Chudleigh, J.H. (2017) ‘Interventions to improve hand hygiene compliance in patient care’, Cochrane Database of Systematic Reviews, Issue 9, CD005186.
Health Research Authority (2023) UK Policy Framework for Health and Social Care Research. London: HRA.
Jenner, E.A., Fletcher, B.C., Watson, P., Jones, F.A., Miller, L. and Scott, G.M. (2006) ‘Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals’, Journal of Hospital Infection, 63(4), pp. 418–422.
Loveday, H.P., Wilson, J.A., Pratt, R.J., Golsorkhi, M., Tingle, A., Bak, A., Browne, J., Prieto, J. and Wilcox, M. (2014) ‘epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England’, Journal of Hospital Infection, 86(S1), pp. S1–S70.
Michie, S., van Stralen, M.M. and West, R. (2011) ‘The behaviour change wheel: a new method for characterising and designing behaviour change interventions’, Implementation Science, 6, 42.
NICE (2014) Infection Prevention and Control (QS61). London: National Institute for Health and Care Excellence.
Nursing and Midwifery Council (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: NMC.
Pittet, D., Hugonnet, S., Harbarth, S., Mourouga, P., Sauvan, V., Touveneau, S. and Perneger, T.V. (2000) ‘Effectiveness of a hospital-wide programme to improve compliance with hand hygiene’, Lancet, 356(9238), pp. 1307–1312.
Sax, H., Allegranzi, B., Uçkay, I., Larson, E., Boyce, J. and Pittet, D. (2007) ‘My five moments for hand hygiene: a user-centred design approach to understand, train, monitor and report hand hygiene’, Journal of Hospital Infection, 67(1), pp. 9–21.
Squires, J.E., Suh, K.N., Linklater, S., Bruce, N., Gartke, K., Graham, I.D., Karovitch, A., Roth, V. and Stockton, K. (2013) ‘Improving physician hand hygiene compliance using behavioural theory: a randomised controlled trial’, BMJ Quality & Safety, 22(9), pp. 756–764.
World Health Organization (2009) WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO.
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