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Original Article
A qualitative study of hand hygiene compliance among health care workers
in intensive care units
Pinar Ay1, Ayse Gulsen Teker1, Seyhan Hidiroglu1, Pinar Tepe1, Aysen Surmen1, Uluhan Sili2, Volkan
Korten2, Melda Karavus1
1 Department of Public Health, School of Medicine, Marmara University, Istanbul, Turkey
2 Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Marmara University, Istanbul,
Turkey
Abstract
Introduction: Studies indicate that adherence to hand hygiene guidelines is at suboptimal levels. We aimed to explore the reasons for poor hand
hygiene compliance.
Methodology: A qualitative study based on the Theory of Planned Behavior as a framework in explaining compliance, consisting four focus
group discussions and six in-depth interviews.
Results: Participants mostly practiced hand hygiene depending on the sense of "dirtiness" and "cleanliness". Some of the participants indicated
that on-job training delivered by the infection control team changed their perception of "emotionally" based hand hygiene to "indication" based.
Direct observations and individual feedback on one-to-one basis were the core of this training. There was low social cohesiveness and a deep
polarization between the professional groups that led one group accusing the other for not being compliant.
Conclusions: The infection control team should continue delivering one-to-one trainings based on observation and immediate feedback. But
there is need to base this training model on a structured behavioral modification program and test its efficacy through a quasi-experimental
design. Increasing social cohesiveness and transforming the blaming culture to a collaborative safety culture is also crucial to improve
compliance. High workload, problems related to work-flow and turnover should be addressed.
Key words: Hand hygiene compliance; qualitative study; healthcare-associated infections; intensive care unit.
J Infect Dev Ctries 2019; 13(2):111-117. doi:10.3855/jidc.10926
(Received 07 October 2018 – Accepted 10 January 2019)
Copyright © 2019 Ay et al. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction
Health-care associated infections (HCAIs) are an
important cause of morbidity and mortality among
hospitalized patients. World Health Organization
estimates that at any given time, the proportion of
patients acquiring at least one HCAI is 7% in developed
and 10% in developing countries. The burden is even
higher among patients in intensive care units (ICUs)
[1,2]. While 30% of ICU patients in high-income
countries are affected by HCAIs, the rate is estimated
as 2-3 folds higher in low and middle-income countries
[1].
Hand hygiene (HH) either performed by washing
hands with soap and water or using alcohol-based hand
rubs is considered as the most important measure for
infection prevention in health care settings. Still studies
indicate that adherence to HH guidelines is at
suboptimal levels. The median compliance to HH
guidelines is estimated as 40% and it is lower in ICUs
compared to the other settings [3].
Mostly nurses have better compliance compared to
physicians. HH is practiced less before patient contact
then after touching a patient suggesting self-protection
as a motivating factor. Also work environment has an
impact on HH practice; high workloads, unavailability
of alcohol based hand rubs and lack of organizational
support deteriorate compliance [3]. While these
findings provide important clues for shaping
intervention strategies, they are still insufficient in
explaining behavioral determinants of HH. Qualitative
research methods can provide a deeper understanding
of behavior since they explore beliefs, attitudes, social
environment and intention [4]. Hence these methods are
being increasingly used in studying compliance to HH
guidelines [5-21].
A recent study carried out through direct
observation at ICUs in our teaching hospital revealed
that the overall HH compliance was 40.6% (U. Sili,
personal communication, March 10, 2016). This figure
might even be an overestimation due to the Hawthorne
Ay et al. – Beliefs and attitudes leading to HH non-compliance J Infect Dev Ctries 2019; 13(2):111-117.
112
effect. Hence the aim of this study is to explore the
reasons for poor HH compliance at ICUs in our teaching
hospital. We use a qualitative approach and apply the
Theory of Planned Behavior (TPB) as a framework in
explaining compliance [22]. TPB indicates that
intention predicts the perceived likelihood of
performing a behavior. Three factors determine
intention; (1) attitude towards behavior, (2) subjective
norms and (3) perceived behavioral control. Attitude to
HH is the overall evaluation of the behavior; it
questions whether performing HH will lead to favorable
or unfavorable outcomes. Social norms take into
consideration whether other people in the social
environment approve or disapprove HH practice. And
perceived behavioral control is the perceived ease or
difficulty of performing HH practice, so it highlights
facilitators and barriers of performing the behavior.
TPB indicates that beliefs are the antecedents of
attitude, social norms and perceived behavioral control.
Hence the model considers behavioral, normative and
control beliefs as the core of intention leading to
behavior [22].
Methodology
Design
This is a qualitative study carried out in a teaching
hospital in Istanbul. The study protocol was developed
through using the Qualitative Research Review
Guidelines – RATS.
Setting and Participants
Medical (8 beds) and Surgical ICUs (16 beds) were
selected as the study area. Physicians (academic staff,
attending physicians, residents, interns) and non-
physicians (nurses, cleaning personnel) working in
these two ICUs were recruited through convenient
sampling.
Medical education lasts six years in Turkey. In the
last year, medical students who are called as “interns”
practice one year of clinical training in their university
hospital. After completing this year, the graduates have
a full license to practice medicine.
Data Collection
Data were collected from a total of 25 participants
through four focus group discussions (FGDs) and six
in-depth interviews (IDIs). FGDs were carried out with
residents, interns and nurses. Each FGD constituted 4-
7 health care workers (HCWs). IDIs were conducted
with academic staff, attending physicians, nurse
supervisor and cleaning personnel. Number of
participants in FGDs and IDIs by profession is
presented on Table 1. Two researchers, a moderator and
an observer carried out the FGDs and IDIs. A semi-
structured interview guide was developed consistent
with the TPB framework in the light of the literature.
All interviews were audio taped after obtaining the oral
consent of the participants.
Analysis
All interviews were transcribed verbatim. Data
were evaluated through thematic content analysis.
Three of the researchers identified key concepts and
categories and developed a coding frame. The initial
coding frame was revised through several readings of
the transcripts. Lastly interviews were re-read
separately by the three researchers and were coded with
the final themes.
Ethical Approval
This study was approved by the institutional clinical
research ethics committee of Marmara University,
School of Medicine (file no: 1400032758). All
participants were included into the study after being
informed and taking their oral consents.
All data were analyzed and presented anonymously.
Results
The ages of the participants ranged from 23 to 45
with a median of 27 years. Among the 25 participants;
Table 1. Number of participants in focus group discussions (FGDs) and in-depth interviews (IDIs) by profession.
Number of FGD/ IDIs
Total number of participants
FGDs
Residents
1
7
Nurses
2
8
Interns
1
4
IDIs
Academic staff
1
1
Attending physicians
2
2
Nurse supervisor
1
1
Cleaning personnel
2
2
TOTAL
4 FGDs and 6 IDIs
25
Ay et al. – Beliefs and attitudes leading to HH non-compliance J Infect Dev Ctries 2019; 13(2):111-117.
113
19 were university graduates, 4 were in the last year of
university (interns) and 2 were high school graduates.
The duration of work in ICUs ranged from 1 month to
12 years with a median of 10 months.
Attitude towards behavior
The role of HH in patient protection
Most of the HCWs indicated that poor HH practices
were the major factor contributing to HCAIs. However,
some participants – although few in number - believed
that poor HH had only a minor role in the development
of infections when compared to the other control
measures. These participants indicated that lack of
physical resources, insufficiency of
cleaning/disinfection of patient-care areas and
transmission through the visitors were the principal
factors leading to infections. Participants with this
perception underestimated the impact of poor HH on
infection development.
“….okay, we’re washing hands but unavoidably
sometimes we’re leaving it out. I don’t believe that HH
is related to these infections actually; sometimes we
admit a patient before the (previous) one is discharged,
before the bed is properly cleaned. So, I don’t think that
it’s all related to handwashing, HH, probably there is a
link (between HH and infections), but not all infections
are related to handwashing.
[What proportion of infections do you think are due
to poor HH practices?]
“I say 20 percent”
Nurse, male
Another factor attributed to the development of
HCAIs was defined as the lack of “leaving the patient
bed or the patient room for rest.” This was brought up
by a cleaning personnel and an intern. These
participants believed that infections occurred because
the patient bed or the patient room was not “left for
rest”, meaning left vacant, at least one day after
discharging the previous infected patient.
“Let’s say that a patient is dead, don’t we need to
rest (the bed) for 24 hours?... But now an infected
patient dies and in half an hour another patient is
admitted to that bed….Infection develops mostly
because of beds. We cleaned the ICU and then an
infected patient came and died, another one came to
that bed and died, as such (the microorganisms)
reproduced. We really are careful. I don’t think that
they (infections) are because of us (our HH practices).
The most important factor is admitting new patients to
the infected patients’ beds right away after they (the
previous ones) have been discharged. We clean the bed
very well when an infected patient dies…But it doesn’t
have any meaning because a new patient comes (to that
bed) in half an hour.’’
Cleaning personnel, female
While most of the health care workers defined
hands as the major vehicle in the development of
infections, there was still an ambiguity on when to
perform HH among some participants. These
participants’ assessment of the need to perform HH was
influenced by the concepts of “cleanliness” and
“dirtiness”. The perception of “dirtiness” was
emotionally sensed. Particularly intimate contact with
patients and bodily fluids lead to the feeling of
“dirtiness”. The procedures which were carried out
outside the ICU were perceived mostly as “clean”.
[How do you decide to perform HH?]
“It is such a sense…If you touch somewhere, you
remember that it was contaminated and you need to
wash”
Nurse, female
Some participants indicated that the training they
got changed their perception of “emotionally” based
HH to “indication” based HH. They indicated that they
were able to understand HH guidelines more clearly
after the training.
[You said that you wash hands when you feel dirty,
so when do you feel dirty?]
“Handwashing when feeling dirty was (something
we did) before the training. There are five principles
(indications for HH). We (started to) wash our hands in
line with these principles after the training. Before it
was according to our emotions. The training was so
beneficial…”
Nurse, female
The training the participants were referring as
“beneficial” was the one-to-one training that was
delivered by the infection control team. The features of
this training are explained in the following section.
The role of HH in self-protection
The need to perform HH when feeling “dirty” might
have shaped from a drive of self-protection. Most of the
participants were anxious of getting infected and
transmitting the infections to their family members. So
HH was indicated to be practiced more frequently and
meticulously after patient contact.
Ay et al. – Beliefs and attitudes leading to HH non-compliance J Infect Dev Ctries 2019; 13(2):111-117.
114
“Primarily, everyone is washing hands after
touching the patient, to protect themselves. Not to
transmit the disease to the patient is the second
concern.”
Nurse, female
Subjective norms
Social cohesion
Participants indicated that their sense of belonging
to the multidisciplinary ICU team was low. Instead they
mostly identified themselves with their own
professional group as “doctors”, “nurses” or the
“cleaning personnel”. This perception was reflected to
the expressions of the participants, they typically used
the concepts of “us” and the “others” during the
interviews. So, whenever an infection developed, each
professional group accused the other for being
inattentive. This problem deepened when a member of
a professional group gave a feedback to a member of
another profession. A simple feedback related to HH
from a doctor to a nurse or vice versa was perceived as
a severe criticism and resulted with a retort. Discussions
were shaped around “you and us” and “blame and
blameful” instead of objectively assessing the situation
where HH was missed.
“I witnessed an argument with an attending
physician and a nurse…One of our attending
physicians informed a nurse colleague. And she
(attending physician) did it so dulcetly, not in a firm
way. She said – look, you forgot to wash your hands
when passing from this place to that place –. She got a
strong reaction from the nurse. The nurse argued back
saying – we (nurses) are doing (HH), we pay so much
attention (to HH), and in reality, you (doctors) are not
doing it–. So, they fall into an argument”
Nurse, female
A feedback given from an HCW to another within
the same professional group was accepted rather easily.
Also, the seniority of the HCW giving feedback and the
wording and style of the feedback determined its
acceptability.
All of the participants indicated that when a
feedback was given from the infection control team
during one-to-one training it was received favorably.
The infection control team was not present in the ICU
constantly, but they had been visiting the ICUs
regularly and giving one-to-one trainings. Infection
control nurses after taking the consent had been
observing the HCWs for some time regarding their
infection control practices. After the observations the
infection control nurse had been giving individual
feedback on one-to-one basis. This kind of on-job-
training was stated to enhance the positive behaviors
while providing an opportunity to correct the wrong
practices. The positive language and the constructive
attitude of the infection control nurse were also
indicated as important determinants of the
communication.
‘’For example, the infection control nurse makes
bed-side visits with our nurses. I see a huge impact of
this….She (the infection control nurse) sometimes
makes observations. She motivates the staff. She says
‘You paid attention to everything, congratulations, this
is good. If she sees a non-compliant staff she says I saw
you, you did such and such, you shouldn’t have done
that…’ She provides an individual based feedback….I
continuously tell them (to clean their hands), but it has
a more impact when someone outside (the ICU) tells
them during a bed-side visit. Also, she doesn’t talk in an
offending way, she talks in a very appropriate
way….The infection control nurse also serves as a role
model (for the staff) during the bed-side visits. She (the
infection control nurse) cleans her hands, and
afterwards I observe my nurses also clean their hands.
…. My colleagues are not irritated by the infection
control nurse…’’
Nurse supervisor, female
The polarization between the professional groups
and its impact was articulated by almost all participants.
Still the desire to form a team spirit and to work in a
peaceful environment was significant in all of the
HCWs. Particularly the directors of ICU and the
attending physicians indicated the need and their
intention to build a collaborative culture in the ICUs.
The role of peer pressure
Participants indicated their colleagues were
supportive regarding HH practices. But a cleaning
personnel indicated that when he carried out the
infection control practices meticulously, he was treated
like a “figure of fun” by his colleagues. He indicated
that when he carried out the procedures in accordance
with the standards, he was made fun of by the other
cleaning personnel. This prevented his motivation to
carry out the patient care activities attentively and in the
appropriate way. He indicated that staff was working in
accordance with the standards only when they were
under the observation of an HCW with a higher
hierarchical position. The cleaning personnel indicated
that most believed that they needed to “know” the
infection control practices, but they didn’t need to
“practice” them.
Ay et al. – Beliefs and attitudes leading to HH non-compliance J Infect Dev Ctries 2019; 13(2):111-117.
115
“Infection (control) nurses come, it changes when
they come but everything reverts back when they go...
The ones who say let it go are predominant. It takes two
or three minutes more work to clean decently from
poorly. These few minutes are neglected so to say. If you
carry out (a task) properly, they (the other cleaning
personnel) look at you weirdly. Like they are making
fun of, I don’t know how to say it…As if they are saying
– look, he is doing it according to the directives - …. We
commonly have this (understanding); know (something)
when you need to say it, learn it, but you don’t have to
practice it”
Cleaning personnel, male
Although the directors of the ICUs were aware that
staff performed HH more often when administrators
were present, they had difficulty addressing it.
Behavioral control
High workload and problems related to work-flow
Increased workload and time constraints were
considered as important barriers to perform HH
practices. All HCWs, but especially nurses and cleaning
personnel worked more intensively. Most of the time,
the patient: nurse ratio was over 2:1. Staff shortage was
mostly result of a high turnover rate. And due to the
high turnover, trainings were carried out repeatedly for
the newcomers.
Increased workload lead to failures in HH practices.
HCWs didn’t have the time to perform HH in every
indication. Sometimes due to the high workload they
couldn’t notice that an indication rose and so missed a
HH opportunity. Also, intense work with problems in
environmental and social conditions lead to burnout. If
the workload was very high, they practiced HH
according to the sense of “dirtiness” not the indications
and were obliged to prioritize self-protection.
“If I take care of two patients I do it more devotedly.
But sometimes we have four patients. Then I start to
wash my hands not for the patient but for my own
health. Because I can’t cope with it. At least I feel clean,
I psychologically feel relieved.”
Nurse, male
Also, emergencies, distractions in the routine work-
flow and obligations to move to other tasks were
considered as important barriers.
Discussion
HH behavior is classified into two types of practice
as inherent and elective handwashing [6,23]. Inherent
HH practices originate from instinctive need to remove
dirt from the skin and are carried out when hands are
visibly soiled or feel sticky. Whitby et al. suggest that
this type of practice shapes during the first decade of
life. HCWs practice inherent HH after touching an
“emotionally dirty area” [6,9,15,23]. Self-protection
which forms the basis for inherent behavior is the
primary motive for HH among HCWs
[6,9,15,18,20,23]. In contrast, HH occurs in more
specific opportunities not encompassed in the inherent
category. This category corresponds to some
indications of HH during patient care. Our results reveal
that HCWs mostly practiced HH depending on the
sense of “dirtiness” and “cleanliness”. Intimate contact
with patients leads to the feeling of “dirtiness” and
resulted with inherent HH practices. Particularly when
time is limited in high work load conditions, HCWs can
act through a self-developed hierarchy of risk for HH.
So elective HH opportunities are omitted and intrinsic
HH is carried out [6]. The high workload with a patient:
nurse ratio over 2:1 would also have led our HCWs to
prioritize inherent HH compared to elective HH.
Some of the participants in our study indicated that
the training they got changed their perception of
“emotionally” based HH to “indication” based HH.
Training was perceived to ease the learning process and
strengthen the rapport of the ICU workers with the
infection control team. But it should be noted that the
training which was referred to be effective was one-to-
one on-job training delivered by the infection control
team. Infection control nurses observed the HCW and
provided immediate feedback supporting the right
practices and offering solutions for improving the
wrong ones. Direct observation and immediate
feedback might provide a more objective assessment
for missed HH opportunities and HH education might
be more effective when delivered in real time as
mistakes occur because multiple demands that require
task prioritization impact attention [24,25].
We suggest that the infection control team should
continue delivering HH trainings based on observation
and immediate feedback. Still there is need to shape this
training model on a structured behavioral modification
program. Fuller et al. evaluated a behaviorally designed
feedback intervention on HH compliance. In the
intervention, HCWs were observed, immediate
feedback was provided on their compliance and they
were helped to formulate an action plan to improve their
behavior. The authors report a moderate but a
significant sustained improvement in HH compliance
compared to routine practice [26]. We suggest to re-
shape these trainings through a structured behavioral
approach and test their efficacy in future studies [6].
Ay et al. – Beliefs and attitudes leading to HH non-compliance J Infect Dev Ctries 2019; 13(2):111-117.
116
Bernard et al. in their work identified three patient
safety cultures: Environmental/ individual safety
culture, blaming safety culture and collaborative safety
culture [27,28]. In the environmental/individual safety
culture biological risks are not linked to the HCW,
rather they are perceived to be present in the
environment. In the blaming safety culture, risks are
perceived to be related to lack of compliance of the
HCW with the infection control practices. And lastly in
the collaborative safety culture, biological risks are
perceived to be prevented and controlled through a team
effort. In our research although few, there were
participants who had underestimated the role of hands
in infection development. These participants considered
that environmental factors were more vital than HH
practice for infection prevention. Some of the methods
they suggested were not even evidence based as
“leaving the patient bed/room for rest”. Studies also
indicated that some HCWs don’t have the correct
understanding of the importance of HH and personal
beliefs about the efficiency of HH might be a barrier
[5,9,13,15,29]. This perception is similar to the
environmental/individual safety culture defined by
Bernard et al. [27,28]. Participants holding this view
underestimate their responsibility in the development of
infections. Also, the higher likelihood of HH behavior
when seniors were present and the concept of “knowing
the infection control practices, but not practicing them”
was linked to this view. Why these participants have
difficulty in failing to recognize the causal role of hands
in infection development should be further explored
and addressed.
Blaming safety culture was the predominant one
observed in our study. Most of the participants were
very well aware that the main reason for infection
development was HCWs’ failure to comply with the
infection control standards. But we observed that low
sense of belonging to the ICU team and low social
cohesiveness mostly prevented these participants to
address the problem effectively. The polarity between
doctors and nurses resulted with one group accusing the
other for not complying with the infection standards.
Studies also show that some staff groups indicate that
they are compliant with HH guidelines while others are
not [13]. Organizational culture is very important in
giving and receiving HH feedback [5,19,30] and we
observed that the blaming safety culture prevented
HCWs to comment on HH practices of their colleagues.
Still it is important that the directors of the ICU and the
attending physicians had indicated their intentions to
build a collaborative safety culture. Highest rate of HH
can be achieved when HCWs perceive HH as a
collective and shared responsibility [17,27,28].
Interventions that address a transformation in the
organizational culture in which HH is an administrative
expectation show promising results [31]. Hence, we
need to find innovative methods to transform the
blaming safety culture to a collaborative safety culture
with a shared accountability.
Our study has some limitations. Firstly, due to its
qualitative nature, our findings can’t be generalized.
Also, there were only few participants from some
groups as academic staff, attending physicians and
cleaning personnel, which might have prevented us to
identify differences between the professional groups.
Some of the HCWs might have not expressed their
opinions freely leading to social desirability bias. We
tried to prevent this bias by securing their
confidentiality.
In conclusion, we suggest that the next step should
be to base the one-to-one training method on a
behavioral modification program and test its efficacy
through a quasi-experimental design. Transforming the
blaming culture to a collaborative safety culture is also
crucial to increase HH compliance. While the directors
of the ICUs have their mindsets ready for this
transformation, we have to work on how to proceed for
such a change since the process is expected to be very
complex and timely. Barriers related to behavioral
control as high workload and problems related to work-
flow should also be addressed. We also have to look
more deeply into the working conditions and
organizational culture that lead to high turnover rates.
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Corresponding author
Uluhan Sili, MD, PhD
Marmara Universitesi, Pendik Egitim ve Arastirma Hastanesi,
Enfeksiyon Hastaliklari Anabilim Dali, Pendik, 34896 Istanbul
Turkey
Tel: +90 216 625 4693
Fax: +90 216 625 4790
Email: uluhan@hotmail.com; uluhan.sili@marmara.edu.tr
Conflict of interests: No conflict of interests is declared.
