Hand Hygiene in the Post-COVID-19 Era

Infection Control TodayInfection Control Today, July/August 2020 (Vol. 24 No. 06)
Volume 24
Issue 6

To enact social change such as better hand hygiene, only about 25% of a group needs to adopt the change and move the rest of the group forward.

Let’s assume that hand hygiene compliance has increased during the coronavirus disease 2019 (COVID-19) pandemic. Now the challenge for infection preventionists (IPs) and others on the frontlines of infection control and prevention: Sustain those gains. But how?

Employ the concepts of behavioral change, including informal leaders, social pressures, cultural norms, and immediate and personal feedback. Informal leaders are people within a work area who are respected and seen as individuals who can be trusted and followed.

Informal leaders can either undo an intervention or change it if they don’t accept it, or they can vastly move a program forward if they are brought in as a stakeholder from the beginning. Social pressures and cultural norms exist on a large scale down to a small scale, such as a profession, hospital, unit within a hospital, and even a shift within the unit. These norms dictate acceptable behaviors, and social pressures can change the norms to reflect changes in what is acceptable for that particular culture.

Finally, personal feedback can help reinforce the behavior that is desired by noticing and praising the person when it’s done. Also, personal feedback that is done through consideration can also be used to help identify when a norm or behaviors don’t meet expectations and to help the person understand what behavior is expected. Successful feedback needs to be timely, specific, and focus on the actions or behavior that is observed.

IPs could perform informal surveys of staff perceptions of hand hygiene in this time and use that information to help find the reasons why people are doing the right thing. They can also use that knowledge to develop campaigns and materials that will continue to encourage positive change. Studies have shown that to enact social change, only about 25% of a group needs to adopt the change and move the rest of the group forward.1

In the past, when there have been major national health threats, such as anthrax attacks and Ebola, the federal government earmarked funding for grants and programs that would be used for public health efforts or for hospitals to obtain training or personnel to focus on preparedness efforts. If funding becomes available for healthcare facilities as a result of increased government grants or programs, it would be ideal to use some of those funds to invest in technology that would improve hand hygiene compliance, such as the electronic monitoring systems.

Another option is telemedicine, using electronic communication to decrease the number of times staff have to come in and out of the patient rooms, therefore removing one of the known barriers to hand hygiene compliance. But ultimately technology cannot solve all the barriers for hand hygiene compliance and, to truly have sustained change, a cultural shift must occur within the facility.

Role modeling, timely feedback, consistent monitoring, and data reports all help support the clean hands culture that is needed in healthcare facilities. At this time, months into the COVID-19 pandemic, some of the behavior change will start to normalize. Before habits return to pre-COVID ways, IPs have the opportunity to build on the renewed importance of hand hygiene in healthcare and start to build the foundations of a new hand hygiene campaign in their facilities.

Leadership involvement is key, as well as finding those informal leaders in the unit level who can be local champions and the role models needed to help drive overall behavior. The core of much of what an IP does requires them to become change agents. A strong change agent needs to be curious, persistent, and collaborative. There are many examples of research on how to influence behavior change and how to utilize some of the informal leaders, social pressure, and feedback to create that culture shift within an organization. An IP does not receive formal education on behavior change science, but it would be beneficial to seek out some of these resources and perhaps work with local and national professional organizations to offer course work, online classes and other avenues to include these topics into the IP trainings.

Behavior change during a pandemic is related to several factors: risk assessment, personal fears, social factors, informational campaigns, and cultural expectations.2 Social factors in a healthcare setting are peer pressure, role modeling, and social comparisons with other units or departments. Also, patients are more acutely aware of the role of hand hygiene in a pandemic and are another source of social pressure to perform.

Hand hygiene has always been the most common way that IPs have talked about preventing the spread of infection, and that has been true with COVID-19. The first item listed on the US Centers for Disease Control and Prevention (CDC) website on how to prevent the spread is hand hygiene and it has been consistently educated to the public. During this time, as the pandemic is making disease transmission and the chain of infection come to life for everyone, hand hygiene is again being seen as everyone’s responsibility.

One challenge to understanding how hand hygiene habits changed in healthcare during COVID-19 is the ability to accurately measure and report compliance data. Hand hygiene is most typically monitored via secret shopper observations. During times of pandemics, the staff who would typically be doing these observations, such as nursing supervisors, ancillary staff, and infection preventionists may be pulled into other duties or not available. Monitoring and observing for hand hygiene may not be a top priority when other patient care concerns are paramount.

Also, secret shopper observations have an inherent flaw in observational bias and Hawthorne effect, which have been recognized as a well-known shortcoming of data reported using that type of data collection. These limitations create a gap in knowledge to understand whether compliance increased or whether that is a perception or assumption.

Changing the culture won’t be easy. It’s been tried again and again and points back to the most basic of questions: Why do healthcare workers not perform hand hygiene, even when they understand the importance of that task to prevent the transmission of infections? Many studies have looked at common reasons why hand hygiene opportunities are missed including: inconvenient placement of dispensers/sink; broken dispenser/sink; distractions; perception of lack of time; inappropriate glove use; skin irritation; workflows do not provide opportunity; and frequent entry and exit of the patient care area.3

Healthcare facilities have struggled with achieving and sustaining high compliance rates of hand hygiene, despite the awareness and knowledge of its importance for centuries. Semmelweis was the first hand hygiene champion in 1858, and was met with disdain at first, eventually gaining some acceptance before being sent to a mental institution.4 Studies have found that, on average, compliance is usually around 50%, with some healthcare workers having more than 100 opportunities for hand hygiene during a normal work shift.5

Electronic hand hygiene monitoring systems have been shown to provide more reliable data and also can improve compliance rates.6 These systems help remove the Hawthorne effect and observation bias associated with secret shopper programs. Also, some have reminder capabilities that would help notify staff when they have nearly missed a hand hygiene opportunity. Another benefit of these programs is the data analytics and ability to share nearly real-time data with staff and leadership. One of the biggest barriers for IP programs to adopt electronic monitoring is the cost associated with establishing and sustaining these programs.

Often IP does not have a budget, and the costs can be substantial, therefore the approval to spend the funds must be made from top leadership of the organization. IPs can help make the business case for these programs, focusing on where other organizations have seen success and published results, use those numbers to get an idea of the changes that could happen and try to equate that to HAIs prevented and potential cost savings for the organization.

During a time of pandemic, many hospitals are actually struggling financially because the usual elective patients are not coming to the hospital. Therefore, there is even less room in budgets to invest in an electronic program.

The process for establishing the cost-benefit analysis of these electronic systems can improve hand hygiene compliance and therefore improve the ability to respond to future outbreaks and keep patients and staff safe.

Given so many reasons why hand hygiene is not performed, as an IP it is important to acknowledge these barriers and attempt to address them within the organization to ensure that healthcare workers can feel supported to do the right thing and be given the type of environment that supports hand hygiene. Part of this includes developing a safety culture within the organization that will encourage compliance with all infection prevention protocols and initiatives.

Rebecca Leach, RN, BSN, MPH, CIC, has been an infection preventionist since 2010, with a background in nursing and epidemiology. Leach, a regular contributor to Infection Control Today®, currently works at a healthcare system in Phoenix that includes 5 hospitals and more than 100 outpatient treatment centers.


  1. Catherine A. Sanderson, CA. Changing social norms in the time of a pandemic. Psychology Today. 03-18-20. PT website. https://www.psychologytoday.com/us/blog/norms-matter/202003/changing-social-norms-in-the-time-pandemic
  2. Samson, A. Under pressure: good behavior in the COVID-19 pandemic. Psychology Today. 5-5-20. PT website. https://www.psychologytoday.com/us/blog/consumed/202005/under-pressure-good-behavior-in-the-covid-19-pandemic
  3. Becker’s Hospital Review. What causes hand hygiene noncompliance? 24 issues.Becker’s website.https://www.beckershospitalreview.com/quality/what-causes-hand-hygiene-noncompliance-24-issues.html
  4. Sohn, E. The shockingly recent history of people actually washing their hands. Popular Mechanics. 04-02-20. PM website. https://www.popularmechanics.com/science/a31982721/history-washing-hands/
  5. Centers for Disease Control and Prevention. Hand hygiene in healthcare settings. CDC website. https://www.cdc.gov/handhygiene/science/index.html
  6. Radtke, J. Improve your hand hygiene compliance rates: three insights from the University of Tennessee Medical Center. Patient Safety & Quality Healthcare. 09-09-19. PSQH website. https://www.psqh.com/analysis/improve-your-hand-hygiene-compliance-rates-three-insights-from-the-university-of-tennessee-medical-center/
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