Date of Award

Spring 6-2022

Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Chanam Shin, PhD, RN

Faculty Reader

Erla Champ-Gibson, PhD, MDiv, RN

Executive Summary

Executive Summary

Introduction: CDI rates have steadily increased in inpatient units (Barker et al., 2017; Hughes et al., 2013; Leal et al, 2019; Tabak et al, 2015; Yanke et al., 2015). CDI has contributed to an increase in hospital stays and costs and has resulted in adverse patient outcomes such as patient deaths attributable to CDI (Leal et al, 2019; Tabak et al, 2015). Although hospitals have implemented algorithm interventions that have been evidenced as effective infection prevention interventions, nursing adherence with CDI algorithms have been low (Barker et al., 2017; Hughes et al., 2013; Yanke et al., 2015). Barriers to CDI algorithm compliance include lack of educational support, limited trainings, and lack of rigid monitoring of CDI algorithm utilization (Hamishehkar et al. 2014; Jansson et al., 2018; Westwell, 2008).

Problems and Purpose Statement: Although hospitals have implemented an algorithm intervention targeting CDI to improve the effectiveness of reducing CDI rates, evidence shows that nursing staff are inconsistent in adhering to CDI protocols and are inadequately trained in applying CDI algorithms. Thus, there is a disconnect between the CDI protocols and the nursing staff’s implementation of those protocols into their daily practice that need to be addressed. The purpose of the QI project was to improve nurse adherence and competency of the CDI algorithm by providing educational interventions. The educational interventions consisted of an online educational session and an educational letter that were aimed to enhance the quality of care and patient safety by increasing the nurses’ awareness of CDI care and improving the nurses’ knowledge and understanding of CDI prevention and treatment.

Methods: This project utilized a one-group pretest-posttest design that included two different types of multifaceted educational interventions: (1) educational letter (Phase One); and (2) an online educational session. In Phase One, the Principal Investigator (PI) sent out the educational letter to the participants (nurses) using the agency hospital’s de-identified group email list three weeks prior to Phase Two. In Phase Two, a 30-minute educational session was conducted to provide the participants opportunities for deeper learning in the evidence-based practice of CDI prevention and treatment as well as improving overall adherence with the CDI protocol. The nursing competency and compliance were measured by utilizing the Likert scale and open-ended question surveys. The surveys were in an electronic format and collected by the online survey service company’s database (Survey Monkey). The participants were asked via email to complete the pre-survey three weeks prior to Phase One and the post-survey three weeks after finishing Phase Two. The flyer containing a Quick Response (QR) code was distributed in the ICU to increase survey response rates. The survey data was placed into the Statistical Package for the Social Sciences (SPSS) software for further evaluation. Descriptive statistics were utilized to summarize and describe the participants’ characteristics. Furthermore, a paired T-test was used to compare the mean differences between the pre- and post-survey data. The qualitative data was stored into Microsoft Excel and manually analyzed to identify patterns and/or themes.

Results/Outcomes: A paired T-test analysis of the pre- and post- survey scores revealed a statistically significant improvement in scores following the educational interventions in this project (p= .003). Moreover, the participants with lower initial competencies showed greater mean differences. Furthermore, the pre- and post- survey data were aggregated and analyzed per each Likert scale question. The results showed statistically significant improvements in nursing competencies related to CDI guidelines as well as prevention resources including the CDI algorithm. The greatest mean increase was noted in question number six, which was focused on the participants’ awareness of the CDI algorithm’s contents. Across the pre- and post-surveys, three themes emerged from the survey data: (1) lack of educational support; (2) quality of care; and (3) increased nursing knowledge and understanding.

Sustainability: There are a couple of ways to achieve sustainability in this project: (1) mentorship; and (2) continuing education. The mentors will offer staff nurses direct resources to identify the problem and implement the CDI algorithm to complete each individual CDI incident. Thus, mentorship of the CDI algorithm will provide an opportunity to sustain positive changes in this project by utilizing a team approach. Additionally, new PDSA cycles for nursing compliance and competency with the CDI algorithm will continue to achieve sustained improvement through continuing nursing education. The continuous education will include online self-learning modules or in-person training sessions that will be offered at flexible hours for nurses. During the new PDSA cycles, all nursing staff will be encouraged to complete the continuing education opportunities and verify their completion with the charge nurses to maintain their compliance and competency with the CDI algorithm.

Implications: This project’s educational interventions, consisting of an educational letter and an educational session, may not completely improve the participants’ CDI algorithm competency. However, the educational interventions in this project may provide a fundamental knowledge of the CDI algorithm’s application and help integrate effective strategies to ensure nursing compliance and competency with an EBP in the prevention and treatment of CDI. Additionally, this project’s PDSA cycle attempted to highlight remaining barriers and unsolved problems that may hinder nursing compliance with the CDI algorithm so that the following PDSA cycles can be more successful by making adjustments to CDI policies and adding new interventions for improvements.


Barker, A. K., Ngam, C., Musuuza, J. S., Vaughn, V. M., & Safdar, N. (2017). Reducing Clostridium difficile in the inpatient setting: A systematic review of the adherence to and effectiveness of C. difficile prevention bundles. Infection Control & Hospital Epidemiology, 38(6), 639–350.

Hamishehkar, H., Vahidinezhad, M., Mashayekhi, S. O., Asgharian, P., Hassankhani, H., & Mahmoodpoor, A. (2014). Education alone is not enough in ventilator associated pneumonia care bundle compliance. Journal of Research in Pharmacy Practice, 3(2), 51–55.

Hughes, G. J., Nickerson, E., Enoch, D. A., Ahluwalia, J., Wilkinson, C., Ayers, R., & Brown, N. M. (2013). Impact of cleaning and other interventions on the reduction of hospital-acquired Clostridium difficile infections in two hospitals in England assessed using a breakpoint model. The Journal of Hospital Infection, 84(3), 227–234.

Leal, J. R., Conly, J., Weaver, R., Wick, J., Henderson, E. A., Manns, B., & Ronksley, P. (2019). Attributable costs and length of stay of hospital-acquired Clostridioides difficile: A population-based matched cohort study in Alberta, Canada. Infection Control and Hospital Epidemiology, 40(10), 1135–1143.

Jansson, M. M., Syrjälä, H. P., Talman, K., Meriläinen, M. H., & Ala-Kokko, T. I. (2018). Critical care nurses' knowledge of, adherence to, and barriers toward institution-specific ventilator bundle. American Journal of Infection Control, 46(9), 1051–1056.

Tabak, Y., Johannes, R., Sun, X., Nunez, C., & McDonald, C. (2015). Predicting the risk for hospital-onset Clostridium difficile infection (HO-CDI) at the time of inpatient admission: HO-CDI risk score. Infection Control & Hospital Epidemiology, 36, 695-701.

Yanke, E., Zellmer, C., Van Hoof, S., Moriarty, H., Carayon, P., & Safdar, N. (2015). Understanding the current state of infection prevention to prevent Clostridium difficile infection: A human factors and systems engineering approach. American Journal of Infection Control, 43(3), 241–247.

Westwell S. (2008). Implementing a ventilator care bundle in an adult intensive care unit. Nursing in Critical Care, 13(4), 203–207.


Copyright Status