Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
Nursing-led culture change in Post Anaesthetic Care Unit (PACU) improved hand hygiene and Bare Below the Elbows (BBE) compliance through simple, sustainable workforce strategies with flow-on benefits to patient safety.
Dates: January 2024 - Ongoing
Implementation sites: Metro South HHS
Partnerships: Healthcare Improvement Unit
Aim
To improve and sustain hand hygiene and BBE compliance in Post Anaesthetic Care Unit (PACU) through a workforce-driven cultural approach that strengthens patient safety and care quality.
Outcomes
- Significant and sustained improvement in BBE and Hand Hygiene audits across two years.
- PACU received formal recognition and an award from Infection Management and Prevention Services (IMPS) in January 2026 for excellence in compliance improvement.
- Staff reported increased awareness of safety behaviours, improved peer accountability, and greater willingness to speak up.
- Enhanced flow-on effects on other clinical practices such as aseptic technique, line management, and equipment handling.
Background
Hand hygiene is one of the simplest yet most powerful actions in healthcare, but is frequently overlooked in high‑acuity environments. In PACU, rapid patient turnover, mixed discipline interactions, and varied perceptions of responsibility contributed to inconsistent Bare Below the Elbows (BBE) and Hand Hygiene practices. Although audits indicated poor compliance, the underlying issue was cultural rather than procedural: staff understood what to do, but inconsistent role modelling, lack of reinforcement, and unclear accountability hindered sustained behavioural change. Recognising that hand hygiene has a significant flow‑on effect, the PACU nursing team identified that improving this single behaviour would positively influence multiple aspects of patient care - including aseptic technique, infection prevention, equipment handling, and situational awareness.
This presented an opportunity to shift from a compliance‑focused model toward a culture - centred approach led entirely by the nursing workforce. Given that the PACU nursing team cannot mandate behaviour for the medical workforce, the project focused on what
nursing staff could control: their own behaviours, peer accountability, and local cultural norms. The central question became: How can a nursing‑led workforce create sustainable hand hygiene improvement in a complex, multidisciplinary environment? This project
aimed to break down perceived “walls” between roles, shift attitudes from individual compliance to shared responsibility, and build confidence among staff to remind, support, and reinforce each other. The need for a psychologically safe environment - one in
which reminders were viewed as patient - safety acts, not criticism - was identified as critical to the project’s success.
Methods
A multi-modal, workforce-driven strategy was implemented over two years (2024–2026), grounded in cultural change principles.
- Education and Awareness
- Brief, frequent micro‑education sessions focusing on the Five Moments of Hand Hygiene and the rationale for BBE. Reinforcement of hand hygiene as a foundational action influencing multiple downstream clinical processes.
- Weekly Leadership Communication
- The NUM issued consistent weekly communications: audit results, success stories, trends, reminders, and encouragement. Shared visibility helped normalise expected practices as part of routine nursing identity.
- Real‑Time Coaching (CN Hand Hygiene Portfolio)
- The CN approached staff in a supportive, non‑punitive way when non‑-compliance was observed.
- Conversations explored barriers (comfort, workflow, jewellery, awareness), and solutions were co‑-designed.
- Peer-to‑Peer Support Culture
- Staff were encouraged to gently remind each other, regardless of seniority. “Speak up for safety” became embedded in daily practice. Reminders became an act of teamwork, not correction.
- Supportive Escalation
- If repeated non‑compliance occurred, a respectful meeting with the NUM, CN, and staff member was held to identify supports. The focus remained constructive rather than disciplinary.
- Normalising the Behaviour
- Reminders and successes were continuously reinforced at handovers, during huddles, and informally at the bedside.
- The consistent presence of champions created visible role modelling.
- This approach used elements of the Model for Improvement, focusing on tests of change (education → reminders → escalation) and iterative reinforcement to embed behaviours into routine practice.
Discussion
This project succeeded because it prioritised culture over compliance and leveraged the strengths of the nursing workforce. The PACU environment is high-acuity, fast‑moving, and multidisciplinary, but the nursing team’s consistent presence made them ideal champions for change. Psychological safety was essential; staff needed confidence to remind each other and trust that reminders were supportive, not punitive.
Lessons Learned
Sustainable improvement requires behavioural and cultural change, not just audits. Consistent messaging from leadership is essential to maintain momentum. Peer reminders are highly effective when norms shift to view them as teamwork. Addressing barriers individually (e.g., jewellery habits, workflow interruptions) increases staff ownership.
Limitations
Influence over medical staff behaviour is limited, as the project focused on nursing staff and cannot enforce compliance for other disciplines. High turnover in PACU requires ongoing orientation and onboarding reinforcement.
Strengths
Completely workforce‑led. Low‑cost, simple, replicable strategies. Recognised by IMPS as a successful example of cultural transformation. Opportunities Expand to include interdisciplinary champions (anaesthetics, allied health). Apply approach to other safety domains (line labelling, aseptic field maintenance, BBE in the wider perioperative environment). Share across other Queensland Health PACUs and procedural areas.
Next Steps
Develop ongoing peer‑champion roles. Integrate hand hygiene culture training into orientation and annual competencies. Showcase model to other units seeking sustainable behaviour change.
References
1. World Health Organization. Five Moments for Hand Hygiene.
2. Australian Commission on Safety and Quality in Health Care. Preventing and Controlling Infections Standard.
3. Clinical Excellence Queensland. Hand Hygiene and BBE Improvement Resources.
Key contact
Bliss Arizala-Nam
Clinical Nurse
Queensland Children's Hospital