Example Reflective Account: Infection Control (Code Section 19)

The third worked example. An IPC learning moment from a peer audit observation. Code Section 19 (reduce risk of harm).

Anonymised and modelled on the pattern of strong submissions.

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Form 6: Reflective Account 3 of 5

Date completed: May 2025 Date of event: March 2025

Field 1: What was the nature of the CPD activity, practice-related feedback, or event in your practice?

In March 2025, my ward was running a hand hygiene audit cycle as part of our quarterly IPC programme. I was paired with an IPC link nurse from a neighbouring ward as the auditor. Over two morning shifts, we observed staff including each other carrying out clinical activities and recorded hand hygiene at each of the WHO 5 moments.

During my own observed shift, the audit results showed that I had completed hand hygiene at moments 1, 2 and 4 reliably but had only completed moment 3 (after body fluid exposure risk) on about 60% of qualifying occasions, and moment 5 (after touching patient surroundings) on roughly 40%.

I had thought my hand hygiene practice was strong. The audit data said otherwise for two of the five moments.

Field 2: What did you learn from the CPD activity, feedback or event?

What I learned was that my pattern of compliance was front-loaded to the moments I had been trained to think of first — before patient contact, before clean procedure, after patient contact. The two moments I missed (moment 3 after body fluid risk, moment 5 after patient surroundings) sit at the back end of the cognitive sequence and are easier to skip when work is busy.

The deeper insight was that I had been confusing competence with reliability. I knew the five moments. I could recite them. I had thought knowing them was enough. The audit data made clear that knowing and doing-every-time were different states, and that my own self-assessment had been overconfident.

I also learned that the moments-3-and-5 pattern was not unique to me. The audit across all observed staff showed similar weighting — strong on moments 1, 2, 4; weaker on 3 and 5. The pattern suggested a systemic training issue, not an individual failure, but the fix at my level was still personal.

Field 3: How did you change or improve your practice as a result?

I have changed two things.

First, I now treat moment 3 (after body fluid exposure risk) as a non-negotiable. Whenever I have removed gloves after any procedure that could have involved body fluid exposure — even when no actual exposure occurred — I perform hand hygiene before moving on to the next task. The behaviour has become near-automatic since April; I notice when I almost don’t do it, which I think is the marker of the new habit taking hold.

Second, I have added a “leaving the bed area” mental trigger for moment 5. Before I step away from any patient’s bed area for any reason, I do hand hygiene. The trigger is physical (the curtain or the side of the bed) rather than task-based, which has made it easier to remember.

A repeat audit on my next observed shift in May showed moment 3 at 95% and moment 5 at 80%. Both still imperfect but materially improved.

Field 4: How is this relevant to The Code?

Code Section 19: Be aware of, and reduce as far as possible, any potential for harm associated with your practice.

Sub-clause 19.3 explicitly requires keeping to and promoting recommended practice in relation to controlling and preventing infection. The WHO 5 moments are the recommended practice. Strengthening compliance on the moments I had been weakest on directly addresses the requirement, and the repeat audit data confirms the change is operational.

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Why this example works

An audit-driven event. The reflection is anchored in measured data, not impression. Audit auditors trust quantitative starting points.

Honest self-assessment. The Field 2 admission that the registrant had been overconfident is the kind of self-awareness that distinguishes genuine reflection from performance.

Specific changes with measurable evidence. The repeat audit numbers in Field 3 are the strongest evidence that the changes were real.

Direct Section 19 link that names sub-clause 19.3 and connects it explicitly to WHO 5 moments compliance.

Variations on the same pattern

The same structure works for many IPC reflections:

• A feedback moment from an IPC link nurse on PPE selection.
• A near-miss involving sharps disposal.
• A learning moment from an outbreak management exercise.
• A specific patient encounter that revealed a gap in your isolation practice.

The features that make the example above strong (specific event, honest self-assessment, concrete change, measurable evidence) apply to all of these.

This is the last of the three worked examples. The next chapter covers the seven most common mistakes audit auditors see in Form 6 entries.