Hand hygiene in hospitals

Behaviour and intention — how to improve hand hygiene in hospitals

Two studies in the hand hygiene-focussed May edition of the Journal of Hospital Infection speak to how improving hand hygiene is both complicated and possible.

Better understanding hand hygiene behaviour through electronic monitoring

The first study, from researchers at the University of Louisville, attempts to discover more about the minutiae of hand hygiene (HH) behaviour. To do this, they turn to electronic hand hygiene monitoring. The previous gold standard, direct observation, is viewed as inherently flawed as it is “subject to various biases including the Hawthorne effect”. People act differently when they know they are being watched by a person. Direct observation is time-consuming, costly and can lead to distorted data. To get lots of data—and lots of accurate data—the researchers turned to electronic hand hygiene monitoring.

This study focusses on an Intensive Care Unit (ICU). This, the authors believe, is novel as “no studies to date have examined HH behaviours in the ICU in great detail.” In this fast-paced environment, what did they find?

Here are some of their observations. Healthcare workers:

  • had better HH compliance at the beginning of their shift, but this rate deteriorates throughout their shift.
  • had better HH compliance on Mondays (31.7%) at the start of a new work week than on Sunday (27.3%), with Wednesday (35.3%) being the day with the best HH compliance rate.
  • had better HH behaviour when leaving a room than when entering it.
  • were more compliant the longer they stayed in a room.

What to learn from this data?
The researchers behind this study identified three ways to improve HH:

  1. Putting alcohol-based sanitizer dispensers dispensers at “highly visible and easily accessible locations to facilitate their use.”
  2. Creating interventions to educate HCW on their potential to transmit diseases and how HH can reduce healthcare-acquired infections.
  3. Using “social influence processes to reinforce behaviour.”

These findings are in-line with other multi-modal approaches to improving hand hygiene behaviour. As a company that is laser-focussed on dispensing, we agree wholeheartedly with the first point and make many accessories to ensure that dispensers can be placed directly at the point-of-use.

The third point is an intriguing one. What exactly do the study authors means by “social influence processes”? Among other things, they are referring to peer pressure and public shaming/encouraging: “public individual feedback showed the most significant improvement in HH compliance over baseline across all roles.”

This area of study—the exploration of the behavioural part of hand hygiene behaviours—is one that is starting to get more attention, including in this next study.

The theory of planned behaviour during the thick of COVID-19 in Hong Kong

As these researchers from the City University of Hong Kong, their city is an important place to study. Whereas global HH compliance rates are around 39%, rates in Hong Kong were 86% in 2006 and rose to 90% in 2020.

The authors used a behavioural model—the theory of planned behaviour (TPB)—to see if it could be used to accurately predict HH behaviour. In doing so, they join a small group of researchers uses TPB to examine HH behaviour.

So, what is the theory of planned behaviour? This theory states that “the best determinant of behaviour is an individual’s intention, which in turn is influenced by three components: attitude, subjective norms and perceived behavioural control.”

What they found was that by examining nurses attitudes, subjective norms, and their perceived behavioural control through a survey, they could effectively predict the nurses’s HH behaviour.

Of the three factors (attitudes, subjective norms, and perceived behavioural control), only attitudes were not helpful for predicting HH behaviour. Subjective norms (“Most people who are important to me would disapprove of me following the hospital’s hand hygiene protocol”) and perceived behavioural control (i.e., “If I want to, I can find a way to comply with the hospital’s hand hygiene protocol”) were important factors for creating a strong intention.

Any project to change human behaviour will be complex, especially one that has as global a scope as the projects to improve hand hygiene behaviour worldwide. The importance of accurate data about HH behaviour and the social norms and controls that people report are an important starting place to reduce HAIs.

The studies:

Using the theory of planned behaviour to explain hand hygiene among nurses in Hong Kong during COVID-19 – Journal of Hospital Infection

Hand hygiene behaviours monitored by an electronic system in the intensive care unit – a prospective observational study – Journal of Hospital Infection


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