By Karin Lillis
Researchers in Ireland confirm that healthcare workers' compliance with hand hygiene guidelines largely relies on workplace culture — from peer and supervisory attitude toward proper protocol and practice to accessibility of necessary supplies like soap and water, and alcohol-based handrubs.
Measuring that compliance has typically relied on a combination of self-reporting, observation and interventional approaches, according to researcher Maura P. Smiddy, MPH, of the Department of Epidemiology and Public Health at University College Cork in Ireland. Smiddy co-authored the report with Rhona O'Connell, PhD, and Sile A. Creedon, PhD, both of the Catherine McCauley School of Nursing and Midwifery, University College of Cork.
“Noncompliance with hand hygiene guidelines is not always attributable to the individual but can be a product of the environment in which they are working," Smiddy says. “The results demonstrate that healthcare workers' compliance with hand hygiene is a complex challenge affected by multiple factors."
Smiddy and colleagues reviewed 10 articles from Australia, Canada, the Netherlands, Taiwan and the United States. Participants—about 415 healthcare workers—included doctors, nurses, allied health professionals and social workers. Data were gleaned from interviews and focus groups.
Factors that influence hand hygiene compliance fall into two categories, the researchers write. Motivational factors include social influences, patient-care acuity, self-protection and the use of cues. Perceptions about the work environment considered resources, knowledge, information and organizational culture.
“The results demonstrate that healthcare workers' compliance with hand hygiene is a complex challenge affected by multiple factors,” Smiddy says. “Motivational factors refer to the influence of self and of others on hand hygiene behaviors. Perceptions of the work environment are often outside of the individual healthcare workers' control. They are dependent on the availability of appropriate resources, educational support, provision of real-time data regarding compliance and an institutional culture permeated with a strong focus on patient safety," she continues. "Noncompliance with hand hygiene guidelines is not always attributable to the individual but can be a product of the environment in which they are working.”
Motivational Factors and Work Environment
Smiddy and colleagues reviewed four specific motivational factors:
Social influences: “Healthcare workers’ compliance with hand hygiene guidelines was influenced by the actions of others from a peer or organizational perspective,” the researchers write. For example, junior medical staff and medical students took their cues from senior physicians. Student nurses also followed the lead of “qualified staff.”
Patient care acuity: “Patient care activities vary in acuity, and in the studies reviewed this was linked to the decisions of healthcare workers’ made in terms of hand hygiene,” the researchers write. Specifically, staff did not delay response to emergency situations, in order to pause and wash their hands. “It is reasonable to expect that where a healthcare professional encounters a critical or lifesaving situation that they will not delay acting to comply with hand hygiene guidelines,” Smiddy and colleagues note.
Self-protection: Self-protection was a consistent motivator to comply with hand hygiene guidelines, the researchers note, but there was a variation among the literature the researchers reviewed about how much perceived protection existed. For instance, the healthcare worker might follow hand hygiene protocol more closely if he or she was handling bodily fluids or treating a patient with pathogens like MRSA. The same could be extended to healthcare workers protecting their families — in preventing the spread of contagious diseases, like SARS. For instance, the healthcare workers said they were more likely to perform hand hygiene when caring for patients with diarrhea or infectious diseases like HIV. They were most likely to comply after exposure to bodily fluids, according to the study.
Use of cues: “Cues trigger memory, attention and decision processes, and therefore trigger behavior,” Smiddy and colleagues write. For example, a dispenser for alcohol-based hand sanitizer might be a visual cue, or the healthcare worker may make it a habit to cleanse his or her hands upon entering and leaving a patient room. Cues positively impact compliance with hand hygiene, but to varying degrees, the authors write.
The researchers considered an additional four factors when they examined perception of the work environment:
Resources: “The time required to complete a task and the facilities available to healthcare workers impacted on their compliance,” the authors write. Heavy workloads and staffing shortages, as well as a lack of readily available hand hygiene products, can contribute to lapses in hand hygiene, Smiddy and colleagues note. “The adequacy of supplies and time to perform hand hygiene are essential to compliance. Convenient access to supplies at the point of care is recommended. Understaffing is linked to suboptimal hand hygiene compliance and an increase in healthcare associated infections,” they write.
Knowledge: Smiddy and colleagues note that knowledge of hand hygiene policies and procedures is directly linked to compliance. In some of the studies reviewed, some healthcare workers did not “have the correct understanding of hand hygiene.” For example, some were not sure whether they should follow the recommended 15- to 20-second rub with an alcohol-based handrub. Using gloves also was viewed as a replacement for washing or cleansing hands. “The provision of education as a standalone intervention or as part of a multifaceted approach is a recognized component of hand hygiene improvement programs,” the authors write.
Information: “Information regarding compliance was considered beneficial in several of the studies,” the researchers note. For example, auditing was seen as an effective tool to encourage and monitor hand hygiene compliance — and being informed about audit results was “important to healthcare workers.” Auditing and timely feedback are considered integral parts of quality improvement in infection prevention and control and patient safety. Electronic monitoring of hand hygiene compliance was generally viewed favorably, the authors also note.
Organizational culture: When a healthcare organization has a culture that supports hand hygiene protocol and provides necessary education supplies, compliance among staff increases.
“Where there was a supportive culture, compliance with hand hygiene guidelines was proved. Where a lack of organizational commitment existed, healthcare workers felt disempowered to correct poor compliance,” the researchers write.
Interpreting the Results
“We need to change how we conduct research particularly in hand hygiene," Creedon says. "The findings should represent a realistic picture of practice. The 'gold standard' is direct observation because it allows interdisciplinary differences to be highlighted as well as differences between compliance with individual guidelines.” The self-recall approach, for example, can be very subjective—asking healthcare workers to evaluate their own compliance can either lead to under- or over-estimating performance, she explains.
Adds O'Connell, "Quantitative studies help reveal some of these complexities but as the studies reviewed mainly lacked a theoretical perspective they were limited in what they could reveal. A new approach to understanding the complexities involved in healthcare practitioner’s compliance with hand hygiene guidelines might be achieved by more robust qualitative studies.”
The bottom line? “Hand hygiene is a patient safety issue and needs to be incorporated into all aspects of clinical care and healthcare planning. The value of hand hygiene needs to be further embedded in the culture of healthcare,” Smiddy says.
“Infection prevention is a patient safety issue, just like patient mortality or failure to rescue,” Creedon adds. She notes that there is a very well-published robust body of research by the National Institutes of Medicine and nursing researcher Linda H. Aiken, PhD, FAAN, FRCN, RN, of the University of Pennsylvania School of Nursing, that have “clarified that the work environment is linked to patient safety issues.”
As Creedon explains, “Essentially, the methods used to compare patient data on, for example, patient morbidity and then compare it to how nurses perceive their working conditions. From that we have learned that fewer patients die when there are more nurses on duty or when the nurses have more education or more clinical expertise. We don't have that same robust approach investigating how the work environment is linked to infection prevention -- including hand hygiene -- but it seems plausible that the same relationship exists.”
Smiddy, M et al. (2015) Systematic qualitative literature review of healthcare workers' compliance with hand hygiene guidelines. American Journal of Infection Control. DOI: http://dx.doi.org/10.1016/j.ajic.2014.11.007.
More Qualitative Research Needed
All of the researchers note there is a need for more qualitative research in hand hygiene compliance. Maura P. Smiddy, MPH, of the Department of Epidemiology and Public Health at University College Cork in Ireland, was the lead researcher. Smiddy co-authored the report with Rhona O'Connell, PhD, and Sile A. Creedon, PhD, both of the Catherine McCauley School of Nursing and Midwifery, University College of Cork. Below, they share their views.
ICT: What prompted your team to conduct this specific study?
Smiddy: There is significant focus on the quantitative literature in relation to hand hygiene with a number of published systematic reviews. I felt that a review of the qualitative literature could potentially provide more depth of understanding when considering healthcare workers' compliance with hand hygiene guidelines.
O’Connell: Multiple studies on compliance with hand hygiene mainly from a quantitative approach, including systematic reviews. There is less information from a qualitative perspective and no systematic review of this literature. Synthesizing qualitative literature can often lead to the generation of new understandings of the topic of interest.
Creedon: We are very familiar with factors that influence compliance with hand hygiene from quantitative research. We wanted to see if there were any different issues emerging from the qualitative literature.
ICT: What are the most significant findings?
Smiddy: I think that the similarity with reported quantitative findings is significant, as well as the lack of theoretically underpinned qualitative studies in this area. A greater focus on the theoretical underpinning of research methodologies needs to be developed. This will improve quality, consistency and comparability between studies. Improving the quality of studies future research will provide methodologically strong evidence to support hand hygiene improvement initiatives and strategies.
O’Connell: There was a lack of theoretical perspective in the qualitative studies reviewed which mainly contained descriptive data. The findings of these qualitative studies were similar to findings from larger studies. This was a limitation of the systematic review as we were unable to generate new understandings as we had hoped. This is a complex issue. Qualitative studies help reveal some of these complexities — but as the studies reviewed mainly lacked a theoretical perspective they were limited in what they could reveal. A new approach to understanding the complexities involved in healthcare practitioner’s compliance with hand hygiene guidelines might be achieved by more robust qualitative studies.
Creedon: I think the most significant finding is the lack of difference between the two bodies of literature. In itself this is reassuring. It means that the same issues need to be addressed.