Behavioral Issues Drive Hand Hygiene Compliance

Since the age of Ignaz Semmelweiss, healthcare practitioners have been admonished to cleanse their hands before coming in contact with patients. While common sense dictated hand hygiene for decades, it wasn’t until 1981 that the Centers for Disease Control and Prevention (CDC) issued the industry’s first evidence-based hand hygiene guideline, according to Larson et al. (2007). Because of fiscal restraints, CDC stopped issuing guidelines in the mid-1980s, but the Association for Professionals in Infection Control and Applied Epidemiology (APIC) stepped in and in 1988 it issued its first hand hygiene guideline (later revised in 1995). When the Healthcare Infection Control Practices Advisory Committee (HICPAC) was created in 1992, it started producing industry guidance, and in 2002 it released an updated hand hygiene guideline that “required major departures from traditional clinical practice,” according to Larson et al. (2007).

These researchers have observed that despite a wide dissemination of national evidence-based practice guidelines, their impact on patient outcomes often go unmeasured. Through surveys and site visits, the researchers measured healthcare-acquired infection (HAI) rates at 40 U.S. hospitals one year before and after publication of the CDC’s hand hygiene guideline and used direct observation of hand hygiene compliance. Larson et al. (2007) report: “All study hospitals had changed their policies and procedures and provided products in compliance with Guideline recommendations; 89.8 percent of 1359 staff members surveyed anonymously reported that they were familiar with the guideline. However, in 44.2 percent of the hospitals, there was no evidence of a multidisciplinary program to improve compliance. Hand hygiene rates remained low (average of 56.6 percent). Rates of central line-associated bloodstream infections were significantly lower in hospitals with higher rates of hand hygiene. No impact of guideline implementation or hand hygiene compliance on other HAI rates was identified.” They surmised further, “Wide dissemination of this guideline was not sufficient to change practice. Only some hospitals had initiated multidisciplinary programs; practice change is unlikely without such multidisciplinary efforts and explicit administrative support.”

If the guideline is not being followed, does it explain the traditionally low compliance rates in U.S. hospitals? Johnston and Bryce (2009) observe, “Studies performed during the last decade have documented reductions in the rates of MRSA and vancomycin-resistant enterococci in hospitals that introduced alcohol-based, waterless hand antiseptics, usually in the context of a general campaign promoting hand hygiene as the cornerstone of safe patient care. Although these and other studies reported improved compliance with hand hygiene, at best compliance improved to 66 percent of opportunities for hand hygiene in one study [Pittet et al., 2000] and 48 percent in another.” [Bischoff et al., 2000]

Perhaps one of the reasons why hand hygiene compliance is so difficult is because compliance itself differs so greatly among different types of healthcare professionals. For instance, Pittet et al., (2000) demonstrated that physicians were the least compliant with handwashing, being performed in just 30 percent of hand-hygiene opportunities.

Johnston and Bryce (2009) note, “Although some studies have demonstrated more success with improving hand-hygiene compliance among physicians, [Trick et al., 2007 and Wisniewski et al. (2007)] the findings by Pittet and colleagues are consistent with other studies [Larson and Kretzer (1995) and Rosenthal et al., (2005)] that have examined compliance with hand hygiene among different types of healthcare providers.”

Could the education level of individuals be a culprit in hand hygiene compliance, or lack thereof? Duggan et al. (2008) set out to evaluate this as a contributing factor in handwashing compliance. The researchers made 2,373 handwashing observations at a teaching hospital approximately 12 weeks before an announced Joint Commission visit and for about 10 weeks after the visit. The rate of handwashing compliance among nurses was 91.3 percent and 72.4 percent among attending physicians. Nurses showed statistically significant improvement in their rate of hand hygiene compliance after the surveyors’ visit but no improvement was seen for attending physicians. The compliance rate in the surgical intensive care unit was more than 90 percent, greater than that in other hospital units. Statistically, the compliance rate was better during the first part of the week than during the latter part of the week, and the compliance rate was better during the 3 p.m. to 11 p.m. shift, compared with the 7 a.m. to 3 p.m. shift. When evaluated by logistic regression analysis, non-physician healthcare worker status and observation after the accreditation visit were associated with an increased rate of hand hygiene compliance. Duggan et al. (2008) note, “An inverse correlation existed between the level of professional educational and the rate of compliance. Future research initiatives may need to address the different motivating factors for hand hygiene among nurses and physicians to increase compliance.”

Whitby, et al. (2006) observe, “Although healthcare worker compliance with handwashing guidelines is a cornerstone of ideal infection control practice, the rate of such compliance has proved to be abysmal.” For years, researchers have studied various interventions to discover how to improve healthcare workers’ knowledge of and compliance with handwashing guidelines and then reinforcing these practices. Whitby, et al. (2006) note that “until recently, none have engendered evidence of sustained improvement during a protracted period.” They add, “Handwashing as a practice is a globally recognized phenomenon; however, the inability to motivate healthcare worker compliance with handwashing guidelines suggests that handwashing behavior is complex. Human behavior is the result of multiple influences from our biological characteristics, environment, education and culture.”

Whitby et al. (2006) used the Theory of Planned Behavior (TPB), explaining that with regard to handwashing, TPB is “predicated on a person’s acceptance that the immediate cause of handwashing is their intention to wash their hands. The intention to perform a given behavior is predicted by three variables: attitude (a feeling that the behavior is associated with certain attributes or outcomes that may or may not be beneficial to the individual), subjective norms (a person’s perception of pressure from peers and other social groups), and perceived behavioral control (a person’s perception of the ease or difficulty in performing the behavior). These variables are predicted by the strength of the person’s beliefs about the outcomes of the behavior, normative beliefs (which are based on a person’s evaluation of the expectations of peers and other social groups), and control beliefs (which are based on a person’s perception of their ability to overcome obstacles or to enhance resources that facilitate or obstruct their undertaking of the behavior).”

Whitby et al. (2006) focused on determining the origin of the behavioral determinants of handwashing of nurses. According to the researchers, handwashing was perceived by the study subjects as a mechanism of self protection against harmful organisms. Handwashing behavior was also influenced by the appearance of their hands. Nurses recognized that handwashing played an integral role in the removal of microbes and the prevention of their transfer, and described the practice as unconscious and habitual, rather than as a thoughtful action associated with particular occasions. Whitby et al. (2006) reported that although nurses appeared to believe that they habitually washed their hands without thinking about it, a number of factors affected the importance they placed on handwashing, including the condition of their patients, the extent of patient contact, their assessment of the task involving a patient, and workload. They note, “Nurses assessed the risk of infection due to contact with patients on the basis of several criteria, including the patient’s diagnosis, physical appearance, and perceived general cleanliness; visibility of the patient’s body fluids; and the patient’s age. An assessment was made in terms of the degree of ‘dirtiness’ or the lack of ‘cleanliness’ of a patient. Handwashing was not always considered to be essential for certain types of physical contact with patients. Tasks that require non-intimate touching of a patient or use of inanimate objects were less likely to be considered important motivating factors for handwashing, compared with tasks involving more-prolonged physical contact. In parallel with the nurse’s assessment of the task involving a patient, nurses judged the level of ‘dirtiness’ of the actual task. This assessment resulted in nursing staff feeling compelled to wash their hands if their hands were visibly contaminated, moist or gritty, or touched axillae, genitals or the groin. Nurses reported that, when under time constraints, they used physical and task assessments to determine the necessity of handwashing. However, nurses always felt compelled to wash hands after performing tasks they considered to be ‘dirty.’”

Behavior is becoming key to understanding hand hygiene compliance, and a new train of thought has emerged that could assist infection preventionists’ efforts.

Behavior Change, Social Marketing and Hand Hygiene Compliance

There is growing thought in the medical literature about the benefits of social marketing in building a hand hygiene compliance program that aims at changing healthcare worker behavior – which is thought to go to the heart of hand hygiene compliance issues. Johnston and Bryce (2009) explain, “Social marketing incorporates commercial marketing technologies to influence voluntary behavior, including not only the behavior of the target audience but also of their immediate society (e.g., patients, other healthcare providers and visitors). [Andreasen, 1995] Interventions, messaging and modes of communication strategically combine and integrate individual, organizational and environmental factors that affect compliance in such a way as to positively influence hand-hygiene behavior. Initial evaluations of the social marketing approach have been positive in other areas of behavior modification, but careful evaluation is crucial to ensure that marketing strategies for hand hygiene have long-term success in effecting change.” [Sax et al., (2007); Mah et al., (2006); and Pinfold (1999)]

A prime example of social marketing was demonstrated by Pinfold (1999) in a hygiene intervention study designed to reduce diarrheal disease transmission by promoting handwashing. Pinfold reports that before the intervention, members of the target audience did not understand the link between poor handwashing and diarrheal disease. A social marketing approach was used to develop a campaign promoting hand hygiene through a variety of communication channels keeping messages simple and in terms understood by the community. Pinfold (1999) notes, “Overall, there was a strong correlation between the number of communication channels remembered by respondents and their knowledge score, with passive channels of printed media such as stickers, posters and leaflets associated with significantly higher scores than other channels... In-depth interviews with conformers and non-conformers suggested that although most knew the intervention messages well enough, the importance they attached to them differed markedly. Thus dissemination of message knowledge was not consistent with the process of dissemination of actual practice.”

Mah et al. (2008) also sought to assess published hand hygiene behavioral interventions that employed a social marketing framework and to recommend improvements to future interventions. Mah and colleagues performed a literature review of published articles about hand hygiene behavioral interventions in healthcare facilities and other communal settings. The researchers report that of 53 interventions analyzed in the review, 16 employed primary formative audience research, five incorporated social or behavioral theories, 27 employed segmentation and targeting of the audience, 44 used marketing strategies, three considered the influence of competing behaviors, seven cultivated relationships with the target audience, and 15 provided simple behavioral messages.

The Robert Wood Johnson Foundation and the Plexus Institute reported results from an analysis of a multifaceted methicillin-resistant Staphylococcus aureus (MRSA) prevention program that employed positive deviance (PD), a novel approach to social and behavioral change, to trigger significant reductions in MRSA incidence ranging from 26 percent to 62 percent at participating hospitals. In addition, as MRSA rates dropped, the hospitals saw a decline in the proportion of Staphylococcus aureus infections caused by methicillin-resistant bacteria, signifying that hospitals can make headway in the fight against drug-resistant superbugs.

"Reports of successful multicenter interventions to reduce endemic antimicrobial resistance problems among U.S. hospitals are extremely rare," says John A. Jernigan, MD, MS, an epidemiologist at the Centers for Disease Control and Prevention (CDC) and part of the CDC team that conducted the analysis. "These extremely encouraging findings add to a growing body of evidence that hospitals can make a difference in their endemic MRSA rates, and further might be able to improve the chances that infected patients have the best possible treatment options available. It shows that hospitals can make an important difference in antimicrobial resistance even at a time when the availability of new antibiotics has stagnated."

In 2006, Plexus, in collaboration with the Positive Deviance Initiative and the CDC, began its MRSA prevention program to examine the effect of using PD in hospitals. PD is based on the premise that, in every organization or community, there are people who solve problems better than peers who have exactly the same resources. The PD process engages frontline hospital staff in discovering and spreading those practices. In other words, PD seeks to engage every person in the health care environment to identify what makes it possible for everyone who comes in contact with patients to take effective infection-control measures at all times.

The three hospitals (Billings Clinic, Billings, Mont.; AlbertEinsteinMedicalCenter, Philadelphia; and University of Louisville Hospital, Louisville, Ky.) that were included in the Partnership and the CDC analysis each undertook activities that included: screening all patients admitted to a pilot unit for MRSA; isolating all patients who tested positive; and rigorously adhering to hand hygiene and contact precautions. The PD approach was included to help all staff members find the best ways to carry out these goals and identify and eliminate barriers to achieving them in their particular institutions.

"Proven infection prevention practices have been known for years, yet most healthcare organizations have been unable to achieve consistently high rates of adherence to these practices. As a consequence, MRSA has become pervasive in almost all hospitals in this country," says Curt Lindberg, DMan, chief learning and science officer of Plexus. "This is the first time the 'what' of proven infection prevention practices has been combined with the 'how' of positive deviance. The results achieved by the hospitals demonstrate the power of this novel combination."

Although each hospital's approach to reducing MRSA infections through PD was different, as is the nature of the intervention, a compelling example of results comes from AlbertEinsteinMedicalCenter, where a patient escort developed a unique method of disposing of his soiled gloves and gown. The escort figured out that by quickly sliding out of the gown, inverting it, folding it tightly and precisely stuffing it into a medical glove, he was able to compress the potential biohazard into a wad the size of a baseball prior to proper disposal, thereby eliminating it as a transmission threat. The technique has since been adopted by others throughout the facility.

"It is innovative activities, such as PD, that may have a transformative impact on infection control efforts, suggesting that MRSA and possibly other drug-resistant infections need not be inevitable. They can be prevented and rates can be turned around," notes Rosemary Gibson, MSc, RWJF senior program officer.

Importance of Education to Hand Hygiene Compliance

Concepts such as social marketing and positive deviance as related to hand hygiene compliance rely in some part on education and training efforts.  Sometimes, understanding what healthcare workers know and like – and what they do not – is the first step toward improved education. Wisniewski et al. (2007) sought to evaluate infection control and hand hygiene understanding at three hospitals by surveying 4,345 healthcare workers three times during a five-year infection control intervention. The researchers found, for example, that all kinds of healthcare professionals preferred to use alcohol-based handrub, that interactive education sessions improved attendance of in-services, and that both of these factors influenced hand hygiene behavior.

Erasmus et al. (2009) sought to study potential determinants of hand hygiene compliance among healthcare workers in the hospital setting. The study was based on responses to structured interviews conducted in nine focus groups involving 65 nurses, attending physicians, medical residents, and medical students working in the intensive care units and surgical departments of five hospitals in the Netherlands. Erasmus et al. (2009) report, “Nurses and medical students expressed the importance of hand hygiene for preventing of cross-infection among patients and themselves. Physicians expressed the importance of hand hygiene for self-protection, but they perceived that there is a lack of evidence that handwashing is effective in preventing cross-infection. All participants stated that personal beliefs about the efficacy of hand hygiene and examples and norms provided by senior hospital staff are of major importance for hand hygiene compliance. They further reported that hand hygiene is most often performed after tasks that they perceive to be dirty, and personal protection appeared to be more important for compliance that patient safety. Medical students explicitly mentioned that they copy the behavior of their superiors, which often leads to noncompliance during clinical practice. Physicians mentioned that their noncompliance arises from their belief that the evidence supporting the effectiveness of hand hygiene for prevention of hospital-acquired infections is not strong. The results indicate that beliefs about the importance of self-protection are the main reasons for performing hand hygiene. A lack of positive role models and social norms may hinder compliance.”

Sometimes, education can improve compliance rates, but the challenge is sustaining this change. Raskind et al. (2007) sought to assess the impact of an educational program on rates of compliance with hand hygiene upon entrance into a neonatal intensive care unit (NICU). In an attempt to improve hand hygiene compliance at a level three NICU, an ongoing hand hygiene promotion educational program was initiated. The program, which targeted all personnel and parents entering the unit, featured modeling and application of recommended hand hygiene practices unique to the NICU. The program emphasized an expectation that all persons entering the unit comply with hand hygiene practices, irrespective of their involvement with patient care. Observations of compliance were performed during three discrete 10-day periods in the 17-bed unit with a single secured main entrance that leads to four, four-bed pods and a single isolation room that opens off a single central hallway. During multiple shifts, unit secretaries trained and proficient in hand hygiene practices served as study monitors and covertly observed hand hygiene compliance and recorded the data on standardized data collection forms.

A first observation period was conducted one month before the intervention and provided baseline hand hygiene compliance rates. Afterward, an ongoing hand hygiene promotion educational program was initiated that used a range of educational materials, including illustrations and a written description of proper hand hygiene techniques specific to the NICU. The hand hygiene techniques involved either the use of soap and water or an alcohol-based antimicrobial hand sanitizer, when appropriate. Indications for the removal of jewelry were noted. The educational materials reinforced the importance, frequency, and consistency of hand hygiene implementation and highlighted the need for hand hygiene on entering the NICU and immediately before and after each patient contact. These materials were disseminated by means of an e-mailed brochure, prominently displayed bulletins and posters that described proper required hand hygiene in the NICU, and verbal reminders. The second and third observation periods were conducted one month and three months after initiation of the educational program, to reassess rates of hand hygiene compliance on entrance into the NICU.

The researchers report that of 497 hand hygiene opportunities observed during the three observation periods, the overall rate of hand hygiene compliance was 94 percent (465 of 497 opportunities). The rate of compliance during the pre-intervention period was 89 percent (168 of 189 opportunities). The researchers add that there was an initial improvement in the rate of compliance at 1 month after the intervention (from 89 percent [168 of 189 opportunities] to 100 percent [212 of 212 opportunities], but the rate decreased to the baseline rate at three months (89 percent [85 of 96 opportunities]).

The researchers note, “This finding suggests that an effective education program may improve hand hygiene compliance. Continued compliance was less apparent in rates observed two months later. This observation is similar to previous evidence that compliance rates tend to return to baseline levels unless sustained with ongoing an audit and continuous reinforcement.” The researchers attribute to the initially improved hand hygiene compliance rates to the Hawthorne effect, which describes how individuals modify their behavior when they become aware that their performance is being monitored. However, but because this study used a discrete method of observation, the Hawthorne effect may not be applicable here.”

Raskind et al. (2007) note further, “Although handwashing is only a single marker for overall compliance with hand hygiene, it is the sine qua non of infection control practices in the NICU. Additionally, screening for hand hygiene compliance at entry to the NICU may reasonably serve as a litmus test that demonstrates the need for additional periodic educational interventions to reinforce compliance with hand hygiene practices. With limited and ever-shrinking healthcare resources, a clean first step into the NICU may translate into improved compliance with hand hygiene overall and shorter, safer hospital courses for the smallest vulnerable patients.”

Observation – and who exactly is doing the observing -- seems to influence whether or not healthcare workers wash their hands. Kohli et al. (2009) sought to determine the impact of known observers on hand hygiene performance in inpatient care units with differing baseline levels of hand hygiene compliance but in a facility where hand hygiene observation and feedback are routine.

Three infection preventionists (IPs) who were well known to staff and a much lesser-known student intern observed hospital staff as part of routine surveillance, and the rates of hand hygiene compliance were compared. The IPs observed 332 opportunities for hand hygiene during 15 observation periods, while the intern observed 355 opportunities during 19 observation periods. The overall rate of compliance observed by the IPs was 65 percent, meaning that in 215 of the 332 opportunities, proper hand hygiene was performed. The overall rate of hand hygiene compliance observed by the intern was 58 percent (or 207 of the 355 opportunities) The researchers note, “Recognized observers are associated with higher rates of hand hygiene compliance, even in a healthcare setting where such observations have become routine. This (Hawthorne effect) is more pronounced in high-performing units and insignificant in low-performing units. The use of unrecognized observers may be important for verifying high performance but is probably unnecessary for documenting poor performance. Moreover, the Hawthorne effect may be a useful tool for sustaining and improving hand hygiene compliance.”

Some experts believe that feedback about hand hygiene performance can increase compliance, but Marra et al. (2008) notes, “Feedback intervention regarding hand hygiene had no significant effect on the rate of compliance. Other measures must be used to increase and sustain the rate of hand hygiene compliance.” The researchers evaluated hand hygiene compliance in two adult step-down units (SDUs) in a tertiary-care hospital in a controlled trial featuring one unit with a feedback intervention program and one without (the control unit). The researchers measured hand hygiene episodes using electronic recording devices and periodic observational surveys. In the intervention unit, feedback was provided by the SDU nurse manager, who explained twice a week to the healthcare workers the goals and targets for the process measures.

A total of 117,579 hand hygiene episodes were recorded in the intervention unit, and a total of 110,718 were recorded in the control unit. There was no significant difference in the amount of chlorhexidine used in the intervention and control units or the amount of alcohol gel used. However, in both units, healthcare workers used alcohol gel more frequently than chlorhexidine. Infection rates in the intervention and control units, respectively, were as follows: for bloodstream infection, 3.5 and 0.79 infections per 1,000 catheter-days; for urinary tract infection, 15.8 and 15.7 infections per 1,000 catheter-days; and for tracheostomy-associated pneumonia, 10.7 and 5.1 infections per 1,000 device-days. There were no cases of infection with vancomycin-resistant enterococci and only a single case of infection with methicillin-resistant Staphylococcus aureus (in the control unit).

Finally, one group of researchers has gone so far as to say that an increase in handwashing does not lead to a reduction in staphylococcal infection. Beggs et al. (2008) observe, “Hand hygiene is generally considered to be the most important measure that can be applied to prevent the spread of healthcare-associated infection (HAI). Continuous emphasis on this intervention has lead to the widespread opinion that HAI rates can be greatly reduced by increased hand hygiene compliance alone. However, this assumes that the effectiveness of hand hygiene is not constrained by other factors and that improved compliance in excess of a given level, in itself, will result in a commensurate reduction in the incidence of HAI.” Beggs et al. (2008) point to other researchers who have identified that the law of diminishing returns to apply to hand hygiene, with the greatest benefits occurring in the first 20 percent of compliance.

In their study, Beggs et al. (2008) sought to evaluate the impact of imperfect handwashing on the transmission of staphylococcal infection and to identify whether there is a limit above which further hand hygiene compliance is unlikely to be of benefit. The researchers theorized that if transmission is only accomplished via healthcare workers’ hands, it should be possible to prevent outbreaks of staphylococcal infection from occurring at a handwashing frequencies of less than 50 percent, even with imperfect hand hygiene. The researchers noted that the relationship between handwashing efficacy and frequency is not linear; meaning that as efficacy decreases, so does handwashing frequency. Beggs et al. (2008) conclude, “Our analysis suggests that there is little benefit to be accrued from very high levels of hand cleansing and that in most situations compliance greater than 40 percent should be enough to prevent outbreaks of staphylococcal infection occurring, if transmission is solely via the hands of healthcare workers.”

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