Interventions to increase hand hygiene compliance in a tertiary university hospital over a period of 5 years: An iterative process of information, training and feedback

Hand hygiene is a core element of patient safety for the prevention of healthcare-associated infections and the spread of antimicrobial resistance. Its promotion represents a challenge that requires a multi-modal strategy using a clear, robust and simple conceptual framework. The World Health Organization First Global Patient Safety Challenge 'Clean Care is Safer Care' has expanded educational and promotional tools developed initially for the Swiss national hand hygiene campaign for worldwide use. Development methodology involved a user-centred design approach incorporating strategies of human factors engineering, cognitive behaviour science and elements of social marketing, followed by an iterative prototype test phase within the target population. This research resulted in a concept called 'My five moments for hand hygiene'. It describes the fundamental reference points for healthcare workers (HCWs) in a time-space framework and designates the moments when hand hygiene is required to effectively interrupt microbial transmission during the care sequence. The concept applies to a wide range of patient care activities and healthcare settings. It proposes a unified vision for trainers, observers and HCWs that should facilitate education, minimize inter-individual variation and resource use, and increase adherence. 'My five moments for hand hygiene' bridges the gap between scientific evidence and daily health practice and provides a solid basis to understand, teach, monitor and report hand hygiene practices.

To elucidate behavioral determinants of handwashing among nurses. Statistical modeling using the Theory of Planned Behavior and relevant components to handwashing behavior by nurses that were derived from focus-group discussions and literature review. The community and 3 tertiary care hospitals. Children aged 9-10 years, mothers, and nurses. Responses from 754 nurses were analyzed using backward linear regression for handwashing intention. We reasoned that handwashing results in 2 distinct behavioral practices--inherent handwashing and elective handwashing--with our model explaining 64% and 76%, respectively, of the variance in behavioral intention. Translation of community handwashing behavior to healthcare settings is the predominant driver of all handwashing, both inherent (weighted beta =2.92) and elective (weighted beta =4.1). Intended elective in-hospital handwashing behavior is further significantly predicted by nurses' beliefs in the benefits of the activity (weighted beta =3.12), peer pressure of senior physicians (weighted beta =3.0) and administrators (weighted beta =2.2), and role modeling (weighted beta =3.0) but only to a minimal extent by reduction in effort (weighted beta =1.13). Inherent community behavior (weighted beta =2.92), attitudes (weighted beta =0.84), and peer behavior (weighted beta =1.08) were strongly predictive of inherent handwashing intent. A small increase in handwashing adherence may be seen after implementing the use of alcoholic hand rubs, to decrease the effort required to wash hands. However, the facilitation of compliance is not simply related to effort but is highly dependent on altering behavioral perceptions. Thus, introduction of hand rub alone without an associated behavioral modification program is unlikely to induce a sustained increase in hand hygiene compliance.

To quantify the different behavioral components of healthcare workers' motivation to comply with hand hygiene in a healthcare institution with a 10-year history of hand hygiene campaigning. Cross-sectional study, by use of an anonymous, self-administered questionnaire. A 2,200-bed university teaching hospital. A stratified random sample of 2,961 medical and nursing staff. A total of 1,042 questionnaires (35.2%) were returned. Of the respondents, 271 (26.0%) were physicians, 629 (60.4%) were nurses, and 141 (13.5%) were nursing assistants. Overall, 1,008 respondents provided information about sex; 718 (71.2%) of these were women. Respondents provided demographic information and data about various behavioral, normative, and control beliefs that determined their intentions with respect to performing hand hygiene. Among behavioral beliefs, the perception that healthcare-associated infections are severe for patients was highly ranked as a determinant of behavior by 331 (32.1%) of the respondents, and the perception that hand hygiene is effective at preventing these infections was ranked highly by 891 respondents (86.0%). Among normative beliefs, perceived social pressure from patients to perform hand hygiene was ranked highly by 760 respondents (73.7%), pressure from superiors was ranked highly by 687 (66.8%), pressure from colleagues was ranked highly by 596 (57.9%), and pressure from the person perceived to be most influential was ranked highly by 687 (68.8%). Among control beliefs, the perception that hand hygiene is relatively easy to perform was rated highly by 670 respondents (65.1%). High self-reported rates of adherence to hand hygiene (defined as performance of proper hand hygiene during 80% or more of hand hygiene opportunities) was independently associated with female sex, receipt of training in hand hygiene, participation in a previous hand hygiene campaign, peer pressure from colleagues, perceived good adherence by colleagues, and the perception that hand hygiene is relatively easy to perform. In a setting with a long tradition of hand hygiene campaigns, behavioral beliefs are strongly in favor of hand hygiene, but adherence is driven by peer pressure and the perception of high self-efficacy, rather than by reasoning about the impact of hand hygiene on patient safety. Female sex, training, and campaign exposure increased the likelihood of compliance with hand hygiene. This additional insight can help to shape future promotional activity.