Changes in various sectors of the healthcare system are constantly taking place. It continues to be a driving force in the quest so as to balance cost containment and improved healthcare quality (Omachonu et al, 2010). Various strategies are implemented to combat hospital acquired infections and there is a high priority to increase compliance rate in hand hygiene practice in the healthcare setting. This is mainly to reduce cross contamination among patients and to ensure not to prolong patients’ stay in the hospital. Therefore, the top management of the hospital deemed necessary that a change is necessary in the current hand hygiene practices. After much discussion, the leader decided on the suggestion of empowering patients to ask the healthcare workers if they had performed hand hygiene before touching them, which was then implemented in a Singapore Government hospital. Empowerment in the healthcare setting basically refers to the process which allows an individual; in this case, the patients to gain knowledge, skills and attitude that are necessary for improved hand hygiene compliance. The introduction of empowering patients ensures that there is an adherence to hand hygiene which is vital in the reduction of infections in the healthcare settings. It is aimed to increase the compliance rate of hand hygiene amongst healthcare workers and also to reduce the number of hospital acquired infections. Therefore, the leader needs to have a clear understanding and to perform efficiently to carry out the planned change. 2. Discussion 2.1 Leadership 2.1.1 Transformational Leadership The constant and continual changes in our healthcare system require a transformational leadership style to be employed by nurse managers. This is imperative as it encourages adaptation to change. The transformational leadership style allows for the recognition of areas in which change is needed and guides change by inspiring followers and creating a sense of commitment (Mary Atkinson Smith, 2011). As a transformational leader, the qualities and characteristics of the nurse manager will enable them to feel confident and comfortable while engaging in the development of healthcare policies and implementation of changes. As this change involves empowering patients, they should be reassured by the leaders to feel important in the participation. The vital goal of transformational leadership is for the leader and the follower to discover meaning and purpose in relation to their work, in tandem with growth and maturity. As transformational leaders in the healthcare setting, their roles include promoting teamwork among staff, encouraging positive self-esteem, motivating staff to function at a high level of performance, and empowering staff to become more involved in the development and implementation of policies and procedures. Moreover, transformational leaders have been associated with positive traits such as improvement in job satisfaction, enhancement of work group collaboration and improvement in patient outcomes (Cummings et al., 2010). Other related characteristics are nurse empowerment, strengthening organizational commitment and increasing overall productivity. A committed nursing leadership and communication amongst team members are vital for the implementation of a change. In order to have increased adherence to hand washing, proper education using visual reminders and feedback are necessary for the introduction of patient empowerment of patients (Maskerine and Loeb, 2006). Nursing leaders must support and positively reinforce hand hygiene practice among healthcare workers. The health belief model which is a theoretical framework can be used to influence and motivate the behaviours of the healthcare workers (Min J.S., 2011). It is a psychological model that focuses on attitudes and individual beliefs’. The health belief model comprises of several key components such as perceived susceptibility, perceived severity, perceived benefits and perceived barriers. By linking the theory to practice, healthcare workers would comply to hand hygiene if they believed that they were predisposed to infection if they did not wash their hands. As such, the staffs’ perceived risk of developing and spreading the infection may be influenced by thorough education on infection control. Staff may perceive severity by having an insight of the serious consequences of infection caused by poor hand hygiene compliance. For instance, prolonged hospital stay, expensive medical costs, and increased morbidity. Staff may perceive benefits with regards to the efficacy of hand hygiene practice when the number of infection amongst patients decreases causing lesser workload. Patient participation can also be a powerful tool to achieve improvements in health care and reduction in hospital acquired infections. 2.2 Innovation in healthcare The continual drive to move from a traditional “disease-centered model” to a more progressive “patient-centered model’ is incomplete without addressing the patient empowerment and engagement movement. As explained by the Agency for Healthcare Research and Quality (AHRQ), in a patient-centered model, patients become active participants in their own care and receive services designed to focus on their individual needs and preferences, in addition to advice and counsel from health professionals (Patient Empowerment in Infection Prevention and Hand Hygiene). Establishing a sustainable and successful change focuses on several fundamental areas that have to be identified and addressed accordingly. They would be namely, Political factors, Economic influences, Sociological trends, Technological innovations, Legal and also Environmental issues (PESTLE). Political Factors 2.3 Change and Change Management Introducing a change to the clinical environment can be challenging and in every change situation, an individual or group must be designated to be the change agent to make this change works (Gebrekidan, 2005). The author has identified the nurses as the main change agents. Reason being, the nurses are those who render most of the bed side nursing care. They also play an important role as a patient advocate by ensuring co- healthcare workers perform hand hygiene as well. 2.3.1 Kurt Lewin’s field theory Kurt Lewin’s theory helps nurses to identify a patient’s barriers to change, how to help the patient become more accepting to the change, and ultimately completing the change. This theory is vital in relation to nursing as this field requires continual effort to help maintain health in populations and change is almost always required to do so. Kurt Lewin model of change is theorized into a three-stage model. The three sequential stages are unfreezing-change-refreeze. In Stage 1, the ‘unfreezing’ stage, involves becoming motivated to change. Change requires adding new forces for change or removal of some of the existing factors that are at play in perpetuating the behaviour (Ross A. Wirth, 2004). In Stage 2, the ‘change’ stage, change is introduced into what needs to be changed.Once there is sufficient dissatisfaction with the current conditions and a real desire to make some change exists, it is necessary to identify exactly what needs to be changed (Ross A. Wirth, 2004). In the last stage, stage 3, ‘refreeze’ takes place. This is where the change is made permanent. Refreezing is the final stage where new behaviour becomes habitual, which includes developing a new self-concept & identity and establishing new interpersonal relationships (Ross A. Wirth, 2004). . 2.3.2 Lippit’s theory of planned change Gordon Lippitt’s theory of planned change expands the work of Kurt Lewin’s field theory. Lippitt’s theory is a goal directed theory in which the change agent uses a process of confrontation to accomplish the change. Lippitt’s change theory is based on bringing in an external change agent to put a plan in place to effect change. There are seven phases in this theory and they are diagnose the problem, assess motivation, assess change agent’s motivation and resources, select progressive change objects, choose change agent role, maintain change, terminate helping relationships (Shirley Melat Ziegler, 2005). (Learning from models may help nurse executives avoid perils such as change fatigue and may promote smoother movement toward safer systems of care. Managing change is a complex, dynamic and challenging process. Effective change has been characterized as unfreezing old behaviours, introducing new ones, and re-freezing them. Failure rates are associated to a number of different factors such as lack of vision and commitment from senior management, limited integration with other systems and processes in the organization, and ill-conceived implementation plans. If organizations are to experience a greater level of success in their development efforts, managers and executives need to have a better framework for thinking about change and an understanding of the key issues which accompany change management.) Havent edit yet 2.4 Use of evidence to support change At present there are limited studies that have been published to assess the efficacy of patient empowerment to improve hand hygiene (Maryanne McGuckin, et.al, 2011). An evidence-based review of programs that have empowered, involved or encouraged patient participation in hand hygiene promotion cannot be conducted by the traditional method focused on quantitative data, linear causality, and ‘scientific’ reliability(Nutbeam, D, 1999). Therefore, the evidence to support change can thus be derived through evaluation for hand hygiene as an individual outcome or as part of a multifaceted program. In relation to the patient engagement and their related healthcare costs, there is a growing body of evidence which demonstrates that patients who are more actively involved in their healthcare experience better health outcomes and incurs lower costs (Patient Empowerment in Infection Prevention and Hand Hygiene). This thus mirrors the author’s view that patient engagement in hand hygiene through patient empowerment can improve health outcomes; achieve better patient care and lower costs. Certain cultural norms about healthcare and authority, as well as norms on perceived gender roles, religion, and age, all impact a patient’s willingness to remind their HCW to perform hand hygiene. The same factors impact a HCW’s willingness to embrace the patient participation concept.( http://www.infectioncontroltoday.com/news/2010/11/strategies-for-patient-empowerment-and-hand-hygiene-compliance.aspx) Evidence-Based Practice Another consideration is work based on evidence. Although hand hygiene practices are poor among healthcare workers, increased hand hygiene compliance with an alcohol-based rub has been attributed to product placement in the environment, convenience of use and the minimal time required for use.9 Supported by the evidence-based research, nursing leaders can implement alcohol-based rub into multidisciplinary approach. Nursing leaders need to value research evidence and support healthcare worker’s hand hygiene practice through products that are more readily available, less expensive and result in better skin integrity of the nurse (http://nursing.advanceweb.com/Infection-Control-Center/IC-Articles/Hand-Hygiene-Compliance-Multidisciplinary-Proactive-Approach.aspx) The Ministry of Health’s Healthcare Performance Group employs Clinical Quality Indicators to fulfill one of its key objectives of monitoring and assessing the clinical performance of hospital institutions so as to facilitate continuous quality improvement and benchmarking. By adopting and tracking Clinical Quality Indicators, the results can be used to compare or benchmark information related to clinical care. Possible problems and/or opportunities for improvement are flagged out within the organisation. The data can help to highlight problem areas in clinical performance, inform or drive quality improvement activities, prompt reflections on clinical practice, ensure proper channeling of resources and identify important issues for further research. Valid and reliable data concerning desired and undesired results play an important role in a comprehensive monitoring and evaluation system. http://www.nuh.com.sg/about-us/clinical-outcomes/hospital-wide-indicators.html Experts suggest there is no single method to measure hand hygiene compliance without human bias (direct observation) or without behavior detail (product usage measurement) (Haas & Larson, 2008; Boyce, 2008) 3. Conclusion Implementing change can be an inevitable and challenging task. Therefore, a good leader is necessary in displaying the positive attributes to influence the rest of the members in the group. Empowering patients to question healthcare workers if they had performed hand hygiene before touching them, provides an improved patient outcome such as better hand hygiene compliance and satisfaction in many of the studies. It also allows an increased compliance rate in hand hygiene as well as reduced hospital associated infections. By being a leader, influencing the individual in efforts toward goal achievement in a given situation is faced with both benefits and barriers. In addition, further evaluations can be done with ongoing feedback reports regarding the patients’ education, staff compliance from clinical audits. The author believes that this change is an enriching experience for the staffs and patients as it concludes to a win-win strategy for improvement of clinical outcomes.