ArticlePDF Available

A qualitative study of hand hygiene compliance among health care workers in intensive care units

Authors:

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.
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.
References
1. World Helth Organization (2017) Health care-associated
infections_Fact Sheet. Available:
http://www.who.int/gpsc/country_work/gpsc_ccisc_fact_shee
t_en.pdf Accessed:06.03.2017
2. Rosenthal VD, Al-Abdely HM, El-Kholy AA, AlKhawaja
SAA, Leblebicioglu H, Mehta Y, Rai V, Hung NV, Kanj SS,
Salama MF, Salgado-Yepez E, Elahi N, Morfin Otero R,
Apisarnthanarak A, De Carvalho BM, Ider BE, Fisher D,
Buenaflor M, Petrov MM, Quesada-Mora AM, Zand F,
Gurskis V, Anguseva T, Ikram A, Aguilar de Moros D,
Duszynska W, Mejia N, Horhat FG, Belskiy V, Mioljevic V,
Di Silvestre G, Furova K, Ramos-Ortiz GY, Gamar Elanbya
MO, Satari HI, Gupta U, Dendane T, Raka L, Guanche-Garcell
H, Hu B, Padgett D, Jayatilleke K, Ben Jaballah N,
Apostolopoulou E, Prudencio Leon WE, Sepulveda-Chavez A,
Telechea HM, Trotter A, Alvarez-Moreno C, Kushner-Davalos
L, Remaining a (2016) International nosocomial infection
control consortium report, data summary of 50 countries for
2010-2015: Device-associated module. Am J Infect Control
44: 1495-1504.
3. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD,
Vos MC, van Beeck EF (2010) Systematic review of studies on
Ay et al. Beliefs and attitudes leading to HH non-compliance J Infect Dev Ctries 2019; 13(2):111-117.
117
compliance with hand hygiene guidelines in hospital care.
Infect Control Hosp Epidemiol 31: 283-294.
4. Forman J, Creswell JW, Damschroder L, Kowalski CP, Krein
SL (2008) Qualitative research methods: key features and
insights gained from use in infection prevention research. Am
J Infect Control 36: 764-771.
5. Smiddy MP, O’Connell R, Creedon SA (2015) Systematic
qualitative literature review of health care workers' compliance
with hand hygiene guidelines. Am J Infect Control 43: 269-
274.
6. Whitby M, McLaws ML, Ross MW (2006) Why healthcare
workers don't wash their hands: a behavioral explanation.
Infect Control Hosp Epidemiol 27: 484-492.
7. White KM, Jimmieson NL, Obst PL, Graves N, Barnett A,
Cockshaw W, Gee P, Haneman L, Page K, Campbell M,
Martin E, Paterson D (2015) Using a theory of planned
behaviour framework to explore hand hygiene beliefs at the '5
critical moments' among Australian hospital-based nurses.
BMC Health Serv Res 15: 59.
8. Dixit D, Hagtvedt R, Reay T, Ballermann M, Forgie S (2012)
Attitudes and beliefs about hand hygiene among paediatric
residents: a qualitative study. BMJ Open 2: e002188.
9. Erasmus V, Brouwer W, van Beeck EF, Oenema A, Daha TJ,
Richardus JH, Vos MC, Brug J (2009) A qualitative
exploration of reasons for poor hand hygiene among hospital
workers: lack of positive role models and of convincing
evidence that hand hygiene prevents cross-infection. Infect
Control Hosp Epidemiol 30: 415-419.
10. Brown B, Crawford P, Nerlich B, Koteyko N (2008) The
habitus of hygiene: discourses of cleanliness and infection
control in nursing work. Soc Sci Med 67: 1047-1055.
11. Ider BE, Adams J, Morton A, Whitby M, Clements A (2012)
Perceptions of healthcare professionals regarding the main
challenges and barriers to effective hospital infection control in
Mongolia: a qualitative study. BMC Infect Dis 12: 170.
12. Joshi SC, Diwan V, Tamhankar AJ, Joshi R, Shah H, Sharma
M, Pathak A, Macaden R, Stalsby Lundborg C (2012)
Qualitative study on perceptions of hand hygiene among
hospital staff in a rural teaching hospital in India. J Hosp Infect
80: 340-344.
13. McLaws ML, Farahangiz S, Palenik CJ, Askarian M (2015)
Iranian healthcare workers' perspective on hand hygiene: a
qualitative study. J Infect Public Health 8: 72-79.
14. Nicol PW, Watkins RE, Donovan RJ, Wynaden D,
Cadwallader H (2009) The power of vivid experience in hand
hygiene compliance. J Hosp Infect 72: 36-42.
15. Salmon S, McLaws ML (2015) Qualitative findings from focus
group discussions on hand hygiene compliance among health
care workers in Vietnam. Am J Infect Control 43: 1086-1091.
16. Squires JE, Linklater S, Grimshaw JM, Graham ID, Sullivan
K, Bruce N, Gartke K, Karovitch A, Roth V, Stockton K,
Trickett J, Worthington J, Suh KN (2014) Understanding
practice: factors that influence physician hand hygiene
compliance. Infect Control Hosp Epidemiol 35: 1511-1520.
17. Uchida M, Stone PW, Conway LJ, Pogorzelska M, Larson EL,
Raveis VH (2011) Exploring infection prevention: policy
implications from a qualitative study. Policy Polit Nurs Pract
12: 82-89.
18. Boscart VM, Fernie GR, Lee JH, Jaglal SB (2012) Using
psychological theory to inform methods to optimize the
implementation of a hand hygiene intervention. Implement Sci
7: 77.
19. Gonzalez ML, Finerman R, Johnson KM, Melgar M,
Somarriba MM, Antillon-Klussmann F, Caniza MA (2016)
Understanding hand hygiene behavior in a pediatric oncology
unit in a low- to mid-income country. J Nurs Educ Pract 6: 1-
9.
20. Marjadi B, McLaws ML (2010) Hand hygiene in rural
Indonesian healthcare workers: barriers beyond sinks, hand
rubs and in-service training. J Hosp Infect 76: 256-260.
21. Piras SE, Lauderdale J, Minnick A (2017) An elicitation study
of critical care nurses' salient hand hygiene beliefs. Intensive
Crit Care Nurs 42: 10-16.
22. Ajzen I (2011) The theory of planned behaviour: reactions and
reflections. Psychol Health 26: 1113-1127.
23. Whitby M, Pessoa-Silva CL, McLaws ML, Allegranzi B, Sax
H, Larson E, Seto WH, Donaldson L, Pittet D (2007)
Behavioural considerations for hand hygiene practices: the
basic building blocks. J Hosp Infect 65: 1-8.
24. Fuller C, Besser S, Savage J, McAteer J, Stone S, Michie S
(2014) Application of a theoretical framework for behavior
change to hospital workers' real-time explanations for
noncompliance with hand hygiene guidelines. Am J Infect
Control 42: 106-110.
25. Son C, Chuck T, Childers T, Usiak S, Dowling M, Andiel C,
Backer R, Eagan J, Sepkowitz K (2011) Practically speaking:
rethinking hand hygiene improvement programs in health care
settings. Am J Infect Control 39: 716-724.
26. Fuller C, Michie S, Savage J, McAteer J, Besser S, Charlett A,
Hayward A, Cookson BD, Cooper BS, Duckworth G, Jeanes
A, Roberts J, Teare L, Stone S (2012) The Feedback
Intervention Trial (FIT)--improving hand-hygiene compliance
in UK healthcare workers: a stepped wedge cluster randomised
controlled trial. PLoS One 7: e41617.
27. Bernard L, Bernard A, Biron A, Lavoie-Tremblay M (2017)
Exploring Canadians' and Europeans' health care professionals'
perception of biological risks, patient safety, and professionals'
safety practices. Health Care Manag 36: 129-139.
28. Bernard L, Biron A, Lavigne G, Frechette J, Bernard A,
Mitchell J, Lavoie-Tremblay M (2018) An exploratory study
of safety culture, biological risk management and hand hygiene
of healthcare professionals. J Adv Nurs 74: 827-837.
29. Jang JH, Wu S, Kirzner D, Moore C, Tong A, McCreight L,
Stewart R, Green K, McGeer A (2010) Physicians and hand
hygiene practice: a focus group study. J Hosp Infect 76: 87-89.
30. Kwok YL, Harris P, McLaws ML (2017) Social cohesion: The
missing factor required for a successful hand hygiene program.
Am J Infect Control 45: 222-227.
31. Larson EL, Early E, Cloonan P, Sugrue S, Parides M (2000)
An organizational climate intervention associated with
increased handwashing and decreased nosocomial infections.
Behav Med 26: 14-22.
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.
... We found that the healthcare workers who attended training activities on hand hygiene are more likely to have a better perception of the issue. This is consistent with other qualitative and quantitative research findings conducted in Turkey and Uttarakhand, India [19,23]. The importance of repeated hand hygiene training for healthcare workers has also been emphasized to reduce hospital-associated infections [7]. ...
Article
Full-text available
Hand hygiene is among the most important factors of infection control in healthcare settings. Healthcare workers are the primary source of hospital-acquired infection. We assessed the current state of hand hygiene knowledge, perception, and practice among the healthcare workers in Qassim, Saudi Arabia. In this cross-sectional study, we used the hand hygiene knowledge and perception questionnaire developed by the World Health Organization. Knowledge and perceptions were classified into good (80-100%), moderate (60-79%), and poor (<60% score). The majority of the healthcare workers had moderate knowledge (57.8%) and perception (73.4%) of hand hygiene. Males were less likely to have moderate/good knowledge compared to females (OR: 0.52, p < 0.05). Private healthcare workers were less likely (OR: 0.33, p < 0.01) to have moderate/good perceptions compared to the government healthcare workers. Healthcare workers who received training on hand hygiene were more likely to have good/moderate perception (OR: 3.2, p < 0.05) and to routinely use alcohol-based hand rubs (OR: 3.8, p < 0.05) than the ones without such training. Physicians are more likely (OR: 4.9, p < 0.05) to routinely use alcohol-based hand rubs than technicians. Our research highlighted gaps in hand hygiene knowledge, perception and practice among healthcare workers in Qassim, Saudi Arabia and the importance of training in this regard.
... Mo et al. (2019) found that women engaged in compensated dating had a higher intention for future HIV testing when their peers were supportive of the behavior. Ay et al. (2019) showed that the subjective norm of healthcare workers towards hand hygiene was influenced by social cohesiveness and a sense of belongingness with the Intensive Care Unit team. White et al. (2015) found that Australian nurses reported that their colleagues influenced their normative beliefs towards hand hygiene the most. ...
... Qualitative research methods can be very helpful because they examine individuals' beliefs, attitudes, experiences and intentions [27]. Based on the review of literature, no qualitative study investigated this issue, so we decided to analyze the experiences and views of healthcare workers qualitatively and discover the barriers to hand hygiene practice in the southeastern Iran. ...
Preprint
Full-text available
Background: Hand hygiene is one of the simplest and most important ways to prevent nosocomial infections. However, the available evidence indicates that hand hygiene is not fully practiced by healthcare workers. Several factors affect hand hygiene. Therefore, this study aimed to explain the experiences of healthcare workers in the barriers to hand hygiene compliance in intensive care units. Methods: This qualitative study was performed on 25 doctors, anesthesiologists, nurses and physiotherapists working in intensive care units by using purposive sampling and semi-structured individual interviews. The data analysis process was performed with Lundman and Graneheim approach. Results: The main theme of “barriers to hand hygiene practice” with three main categories, including 1- barriers related to healthcare providers with subcategories of workload, insufficient knowledge, inappropriate attitude and wrong behavioral patterns, 2- barriers related to management with the subcategories of improper planning and training, improper design of the physical space of the department and 3- barriers related to equipment and facilities with the subcategories of lack of equipment and poor quality equipment were identified in this study. Conclusion: The results of the present study can help the relevant authorities in adopting appropriate strategies to remove barriers to hand hygiene practice and promote the right attitude and behavior in healthcare workers.
... The transcripts produced were cleaned and coded by three people, each using the CHC intervention implementation plan with (1) the defined target audience for the intervention, (2) the health education topics planned for the intervention, (3) the activities planned during the implementation of CHC intervention, (4) the recommended behavior and practices for beneficiaries, (5) the recommended facilities in homes of beneficiaries, and (6) the supporting role of village leader and health center. The coding was harmonized to reduce bias (Ay et al., 2019;RMoH, 2010 ). In plenary session, the codes were put into categories and later in themes using both an inductive and deductive approach based on the CHC intervention plan from RMoH (2010), the framework of effective implementation (Day et al., 2019;Durlak & DuPre, 2008 ) and the principles of the implementation process of a public health campaign (NASEM, 2017). ...
Article
Effective implementation of health interventions is critical for maximum adoption and optimal health outcomes. This qualitative study assessed the differences in Community Health Club (CHC) implementation in villages using qualitative research methods. Villages in Rusizi district in Rwanda were purposively selected with high, medium, and low adoption rates. The results revealed that the traits and skills of intervention facilitators (providers or implementers) at the village level, the involvement of the head of the village in the CHC intervention activities, and the support supervision by the Community Environmental Health Officer from the health center may have contributed to high rates of adoption of the intervention. Poor community organization, mistrust, lack of equal consideration among intervention beneficiaries, and lack of skills and capacity for intervention facilitators may have contributed to the low rates of intervention adoption. The results of this study suggest the need for capacity building of implementers, local leaders, and supervisors for improved (1) skills to adapt to local contexts and maximize the intervention adoption, (2) involvement and participation of local leadership, and (3) support supervision, guidance, and close monitoring, respectively. for effective implementation and maximum adoption of CHC intervention.
Article
Full-text available
Background Global pandemic outbreaks often have people fear. Healthcare personnel (HCP), especially those fighting the pathogens at the front lines, encounter a higher risk of being infected, while they treat patients. In addition, a variety of environmental fomites in hospitals, which may contain infectious agents, can post a high risk of getting infectious diseases. Aim Making HCP feel safe from infectious diseases is critical to delivering the best healthcare practice. Therefore, this study aims provide a better understanding of HCP’s HH behaviours and perceptions of infectious diseases from psychological perspectives. Method Observations measured different environmental features at three different departments and questionnaires asked HCP’s perception of safety from infectious diseases and coping behaviors (e.g., avoidance and disinfection). Findings This study has implications for potential interventions that enough HH stations at convenient locations would increase HH compliance rate from psychological perspectives, perception of safety from infectious diseases. In response to the current research gap in psychological aspects associated with HH, this study also presents HCP’s coping behaviours (e.g., avoidance and disinfection) would be predicted by their perceived contamination likelihoods and their perceived vulnerability enhanced the associations. Conclusions Nonetheless, due to several limitations, those findings should be carefully interpreted and further studies must be conducted with more solid academic rigor.
Article
Full-text available
Background: There are limited explorations into hospital staff reactions to automated hand hygiene surveillance or hand hygiene interventions. Methods: An automated surveillance system with daily feedback and a behavioral intervention component was trialed in 2 wards in an Australian tertiary teaching hospital. After 9 months, 12 clinicians from each ward were interviewed prior to the completion of the trial to explore satisfaction with the system and behavioral component of nudging each other with a reminder to comply. Only on completion of the trial were transcripts analyzed for themes. Results: Staff from the ward with improved compliance described a socially cohesive team with a well-liked nurse unit manager who accessed daily compliance rates and worked with staff to set goals. This contrasted with the ward without improvement in compliance, whose staff described their great reluctance and discomfort to nudge each other to comply and distrust of the authenticity of the rates established from the automated system. Conclusions: Interventions for improving compliance are more likely to be successful in a ward with a social cohesive team. Patient safety interventions, in the first instance, may benefit from purposeful selection of wards with cohesive teams and skilled leaders who can transform clinicians into early adopters of the program.
Article
Full-text available
It is accepted by hospital clinical governance that every clinician's "duty of care" includes hand hygiene, yet globally, health care workers (HCWs) continue to struggle with compliance. Focus group discussions were conducted to explore HCWs' barriers to hand hygiene in Vietnam. Twelve focus group discussions were conducted with HCWs from 6 public hospitals across Hanoi, Vietnam. Discussions included participants' experiences with and perceptions concerning hand hygiene. Tape recordings were transcribed verbatim and then translated into English. Thematic analysis was conducted by 2 investigators. Expressed frustration with high workload, limited access to hand hygiene solutions, and complicated guidelines that are difficult to interpret in overcrowded settings were considered by participants to be bona fide reasons for noncompliance. No participant acknowledged hand hygiene as a duty of care practice for her or his patients. Justification for noncompliance was the observation that visitors did not perform hand hygiene. HCWs did acknowledge a personal duty of care when hand hygiene was perceived to benefit her or his own health, and then neither workload or environmental challenges influenced compliance. Limited resources in Vietnam are amplified by overcrowded conditions and dual bed occupancy. Yet without a systematic systemic duty of care to patient safety, changes to guidelines and resources might not immediately improve compliance. Thus, introducing routine hand hygiene must start with education programs focusing on duty of care. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Article
Full-text available
Improving hand hygiene among health care workers (HCWs) is the single most effective intervention to reduce health care associated infections in hospitals. Understanding the cognitive determinants of hand hygiene decisions for HCWs with the greatest patient contact (nurses) is essential to improve compliance. The aim of this study was to explore hospital-based nurses’ beliefs associated with performing hand hygiene guided by the World Health Organization’s (WHO) 5 critical moments. Using the belief-base framework of the Theory of Planned Behaviour, we examined attitudinal, normative, and control beliefs underpinning nurses’ decisions to perform hand hygiene according to the recently implemented national guidelines. Thematic content analysis of qualitative data from focus group discussions with hospital-based registered nurses from 5 wards across 3 hospitals in Queensland, Australia. Important advantages (protection of patient and self), disadvantages (time, hand damage), referents (supportive: patients, colleagues; unsupportive: some doctors), barriers (being too busy, emergency situations), and facilitators (accessibility of sinks/products, training, reminders) were identified. There was some equivocation regarding the relative importance of hand washing following contact with patient surroundings. The belief base of the theory of planned behaviour provided a useful framework to explore systematically the underlying beliefs of nurses’ hand hygiene decisions according to the 5 critical moments, allowing comparisons with previous belief studies. A commitment to improve nurses’ hand hygiene practice across the 5 moments should focus on individual strategies to combat distraction from other duties, peer-based initiatives to foster a sense of shared responsibility, and management-driven solutions to tackle staffing and resource issues. Hand hygiene following touching a patient’s surroundings continues to be reported as the most neglected opportunity for compliance.
Article
Full-text available
Acquisition of a health care-associated infection is a substantial risk to patient safety. When health care workers comply with hand hygiene guidelines, it reduces this risk. Despite a growing body of qualitative research in this area, a review of the qualitative literature has not been published. A systematic review of the qualitative literature. The results were themed by the factors that health care workers identified as contributing to their compliance with hand hygiene guidelines. Contributing factors were conceptualized using a theoretical background. This review of the qualitative literature enabled the researchers to take an inductive approach allowing for all factors affecting the phenomenon of interest to be explored. Two core concepts seem to influence health care workers' compliance with hand hygiene guidelines. These are motivational factors and perceptions of the work environment. Motivational factors are grounded in behaviorism, and the way in which employees perceive their work environment relates to structural empowerment. Noncompliance with hand hygiene guidelines remains a collective challenge that requires researchers to adopt a consistent and standardized approach. Theoretical models should be used intentionally to better explain the complexities of hand hygiene. Copyright © 2015 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Article
Full-text available
Objective: To identify the behavioral determinants--both barriers and enablers--that may impact physician hand hygiene compliance. Design: A qualitative study involving semistructured key informant interviews with staff physicians and residents. Setting: An urban, 1,100-bed multisite tertiary care Canadian hospital. Participants: A total of 42 staff physicians and residents in internal medicine and surgery. Methods: Semistructured interviews were conducted using an interview guide that was based on the theoretical domains framework (TDF), a behavior change framework comprised of 14 theoretical domains that explain health-related behavior change. Interview transcripts were analyzed using thematic content analysis involving a systematic 3-step approach: coding, generation of specific beliefs, and identification of relevant TDF domains. Results: Similar determinants were reported by staff physicians and residents and between medicine and surgery. A total of 53 specific beliefs from 9 theoretical domains were identified as relevant to physician hand hygiene compliance. The 9 relevant domains were knowledge; skills; beliefs about capabilities; beliefs about consequences; goals; memory, attention, and decision processes; environmental context and resources; social professional role and identity; and social influences. Conclusions: We identified several key determinants that physicians believe influence whether and when they practice hand hygiene at work. These beliefs identify potential individual, team, and organization targets for behavior change interventions to improve physician hand hygiene compliance.
Article
Full-text available
Background: Hand hygiene (HH) has been identified as one of the simplest, but most important, methods to prevent cross-infection in healthcare facilities. In spite of this fact, the HH compliance rate remains low among healthcare workers (HCWs). Several factors may affect HH behavior. In this study, we aimed to assess various aspects of HH from the perspective of HCWs. Method: This qualitative study was conducted in two hospital settings in Shiraz, Iran. Eight focus group discussions (FGDs) and six in-depth interview sessions were held with ICU and surgical ward nurses, attending physicians, medical and nursing students and supporting staff. Each FGD and interview was transcribed verbatim, open codes were extracted, and thematic analysis was conducted. Results: Three themes emerged from the thematic analysis including: "the relationship between personal factors and HH compliance," "the relationship between environmental factors and HH compliance" and "the impact of the health system on HH adherence, including the role of adequate health systems, administrative obligations and the effect of surveillance systems." Conclusion: Several factors played a significant role in improving HCWs HH compliance, such as the regular adherence to health system tenets. HH compliance may be improved through application of realistic policies and better supervision. In addition, appropriate education may positively affect HH behavior and attitudes.
Article
Full-text available
Insufficient use of behavioral theory to understand health care workers' (HCWs) hand hygiene compliance may result in suboptimal design of hand hygiene interventions and limit effectiveness. Previous studies examined HCWs' intended, rather than directly observed, compliance and/or focused on just 1 behavioral model. This study examined HCWs' explanations of noncompliance in "real time" (immediately after observation), using a behavioral theory framework, to inform future intervention design. HCWs were directly observed and asked to explain episodes of noncompliance in "real-time." Explanations were recorded, coded into 12 behavioral domains, using the Theory Domains Framework, and subdivided into themes. Over two-thirds of 207 recorded explanations were explained by 2 domains. These were "Memory/Attention/Decision Making" (87, 44%), subdivided into 3 themes (memory, loss of concentration, and distraction by interruptions), and "Knowledge" (55, 26%), with 2 themes relating to specific hand hygiene indications. No other domain accounted for more than 18 (9%) explanations. An explanation of HCW's "real-time" explanations for noncompliance identified "Memory/Attention/Decision Making" and "Knowledge" as the 2 behavioral domains commonly linked to noncompliance. This suggests that hand hygiene interventions should target both automatic associative learning processes and conscious decision making, in addition to ensuring good knowledge. A theoretical framework to investigate HCW's "real-time" explanations of noncompliance provides a coherent way to design hand hygiene interventions.
Article
Aims: The objectives of the study were to: (1) examine the relationships between three different qualitative perceptions of safety culture and the Canadian Patient Safety Climate Survey factors; (2) determine whether these perceptions are associated with different hand hygiene practices. Background: Healthcare-associated infections and safety cultures are a worldwide issue. During the A/H1N1 Influenza pandemic, Europe and North America did not have the same responses. Importantly, healthcare professionals' perceptions can influence patient safety through infection prevention practices like hand hygiene. Design: A cross-sectional design was used with data collected in 2015. Methods: The Canadian Patient Safety Culture Survey and hand hygiene observations were gathered from three healthcare centers (2 Canadian and 1 European). Descriptive analyses and ANOVAs were conducted to explore healthcare professionals' safety perceptions and practices. Results: The rates of hand hygiene practices varied widely between the three sites, ranging from 35-77%. One site (Site 3) was found to have the highest scores of management follow-up, feedback about incidents, supervisory leadership for safety, unit learning culture and senior leadership support for safety, as well as the highest levels of overall patient safety grades for the unit and organization. Conclusion: The quantitative results of this study support the previously described model based on qualitative results: individual culture, blaming culture and collaborative culture. Differences between continents emerged regarding infection prevention practices and the way we qualify infections. The results raise concerns about infection practices and about safety cultures and challenges worldwide. This article is protected by copyright. All rights reserved.
Article
Aim: To describe critical care nurses' hand hygiene attitudinal, normative referent, and control beliefs. Background: Hand hygiene is the primary strategy to prevent healthcare-associated infections. Social influence is an underdeveloped hand hygiene strategy. Methods: This qualitative descriptive study was conducted with 25 ICU nurses in the southeastern United States. Data were collected using the Nurses' Salient Belief Instrument. Results: Thematic analysis generated four themes: Hand Hygiene is Protective; Nurses look to Nurses; Time-related Concerns; and Convenience is Essential. Conclusion: Nurses look to nurses as hand hygiene referents and believe hand hygiene is a protective behaviour that requires time and functional equipment.
Article
Patient safety has become a worldwide concern in relation to infectious diseases (Ebola/severe acute respiratory syndrome/flu). During the pandemic, different sanitary responses were documented between Europe and North America in terms of vaccination and compliance with infection prevention and control measures. The purpose of this study was to explore the health care professional's perceptions of biological risks, patient safety, and their practices in European and Canadian health care facilities. A qualitative-descriptive design was used to explore the perceptions of biological risks and patient safety practices among health care professionals in 3 different facilities. Interviews (n = 39) were conducted with health care professionals in Canada and Europe. The thematic analysis pinpointed 3 main themes: risk and infectious disease, patient safety, and occupational health and safety. These themes fit within safety cultures described by participants: individual culture, blame culture, and collaborative culture. The preventive terminology used in the European health care facility focuses on hospital hygiene from the perspective of environmental risk (individual culture). In Canadian health care facilities, the focus was on risk management for infection prevention either from a punitive perspective (blame culture) or from a collaborative perspective (collaborative culture). This intercultural dialogue described the contextual realities on different continents regarding the perceptions of health care professionals about risks and infections.