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A Qualitative Exploration of Reasons for Poor Hand Hygiene Among Hospital Workers:

Lack of Positive Role Models and of Convincing Evidence That Hand Hygiene Prevents
Author(s): V. Erasmus ,MSc, W. Brouwer ,MSc, E.F. vanBeeck ,MD,PhD, A. Oenema
,PhD, T.J. Daha, J.H. Richardus ,MD,PhD, M.C. Vos ,MD,PhD, J. Brug and PhD
Source: Infection Control and Hospital Epidemiology, Vol. 30, No. 5 (May 2009), pp. 415-419
Published by: Cambridge University Press on behalf of The Society for Healthcare
Epidemiology of America
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infection control and hospital epidemiology may 2009, vol. 30, no. 5

original article

A Qualitative Exploration of Reasons for Poor Hand Hygiene

Among Hospital Workers: Lack of Positive Role Models
and of Convincing Evidence That Hand Hygiene
Prevents Cross-Infection

V. Erasmus, MSc; W. Brouwer, MSc; E. F. van Beeck, MD, PhD; A. Oenema, PhD; T. J. Daha;
J. H. Richardus, MD, PhD; M. C. Vos, MD, PhD; J. Brug, PhD

objective. To study potential determinants of hand hygiene compliance among healthcare workers in the hospital setting.
design. A qualitative study based on structured-interview guidelines, consisting of 9 focus group interviews involving 58 persons and
7 individual interviews. Interview transcripts were subjected to content analysis.
setting. Intensive care units and surgical departments of 5 hospitals of varying size in the Netherlands.
participants. A total of 65 nurses, attending physicians, medical residents, and medical students.
results. 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.
conclusion. 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.
Infect Control Hosp Epidemiol 2009; 30:415-419

Hospital-acquired infections are a major threat to patients and research.11,12 Qualitative research can provide valuable insight
place a great burden on national healthcare services.1,2 This into possible behavioral determinants13,14 and is often the first
problem must be combated with an adequate level of hand step in a stepwise approach to intervention development.15
hygiene compliance, which is of crucial importance in pre- Qualitative methods have, however, rarely been used to evaluate
venting cross-transmission3-5 and has been identified as a health hand hygiene compliance among healthcare workers. Com-
policy priority.1,6 However, the level of hand hygiene compli- pliance with hand hygiene among different groups of hospital
ance remains low worldwide, and it was termed unacceptably workers may be influenced by beliefs and norms that vary
poor by a public health authority in London, United King- across the groups. Review of the international literature reveals
dom.7 Interventions aimed at improving hand hygiene com- that the hand hygiene behavior of nurses has been studied
pliance have been implemented, but the effects of these inter- most extensively.16,17 Physician compliance is often found to be
ventions remain modest and/or of short duration.8,9 To develop lower than that of nurses,18,19 although the reason for this is
interventions with more-pronounced and sustainable effects, not always clear. Medical students hand washing behavior has
information is needed on the behavioral determinants of hand rarely been studied,20 although research into their behavior
hygiene compliance.10 This topic has only recently started re- could provide essential knowledge on how tomorrows phy-
ceiving attention by investigators involved in hand hygiene sicians could be stimulated to comply with hand hygiene guide-

From the Departments of Public Health (V.E., W.B., E.F.v.B., A.O., J.H.R.) and Medical Microbiology and Infectious Diseases (M.C.V.), University Medical
Center Rotterdam, Rotterdam, the Dutch Society for Hygiene and Infection Prevention in Healthcare, Leiden (T.J.D.), and the EMGO Institute, Amsterdam
(J.B.), the Netherlands.
Received August 20, 2008; accepted December 4, 2008; electronically published April 2, 2009.
2009 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2009/3005-0002$15.00. DOI: 10.1086/596773

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416 infection control and hospital epidemiology may 2009, vol. 30, no. 5

lines and thereby break the cycle of poor physician hand hy- table. Topics Covered to Lead Focus Group Discussions
giene.2 The present study is a qualitative exploration of reasons and Interviews
for poor hand hygiene compliance among nurses, medical stu- Topic, discussion point(s)
dents, and physicians in the hospital setting in the Netherlands.
What are reasons for (non)compliance?
methods What are (dis)advantages of hand hygiene?
Participants Who benefits from hand hygiene?
How important is hand hygiene?
A total of 9 focus groups and 7 individual interviews were When do you like to perform hand hygiene?
conducted with healthcare professionals. Participants were Subjective norms
recruited from 5 Dutch hospitals. The hospitals included were How do other healthcare workers influence hand hygiene
1 small general hospital (!400 beds), 1 large general hospital behavior?
(1400 beds), 1 top clinical teaching hospital (1400 beds), and Perceived behavioral control
2 university teaching hospitals (1400 beds each). Participants Does anything prevent healthcare workers from perform-
ing hand hygiene?
worked in the intensive care unit (ICU) or surgical ward of
How could hand hygiene be stimulated?
these hospitals. Twenty-four participants were non-ICU
nurses, 23 were ICU nurses, 4 were attending physicians, 3
were residents, and 1 were medical students. All focus groups ioral control concerning compliance with hand hygiene stan-
were homogenous with respect to profession and hospital. To dards. According to the Theory of Planned Behavior, these
ensure maximum levels of participation, the focus groups and constructs predict the intention for engagement in the be-
individual interviews were held on location. The individual havior under study, and readiness to change hand hygiene
interviews were conducted with physicians, because their behavior was also explored. The Theory of Planned Behavior
schedules did not allow focus group participation. has been used in previous studies to explain hand hygiene
behavior.12,16 Earlier studies have indicated that perceived so-
Focus Group Interviews
cial influences other than subjective norms, such as example-
The 9 focus group interviews took 3060 minutes and in- setting behaviors by others (ie, modeling) and direct social
cluded 410 participants. All interviews were led by a mod- support, may be important for a range of behaviors15; these
erator (V.E.) and were supported by an assistant. At the start potential social influences were also included in the interview
of the interview, it was emphasized that the interview was guide.
not a test (ie, that there were no good or bad answers) and
that all opinions were respected. Furthermore, the partici- Analysis
pants were encouraged to discuss their opinions openly, to
Interview transcripts underwent systematic content analysis
increase the diversity of perspectives. All focus groups were
for collection of qualitative data, using Nvivo software, ver-
recorded with a voice recorder and were fully transcribed.
sion 7. After content analysis, data were assigned codes, and
Face-to-Face Interviews code-specific reports were generated to detect common
themes and key points. Content analysis was performed in-
The 7 face-to-face interviews took 2050 minutes. All inter- dependently by 2 researchers (V.E. and W.B.). Disagreements
views were led by an interviewer (V.E.). Again, it was ex- were resolved by a third researcher (J.B.).
pressed during the introduction that the interview was not a
test and that all answers and information were useful. All results
interviews were also recorded with a voice recorder and were
fully transcribed. All participants admitted that noncompliance to the hand
hygiene guidelines at their respective institutions occurred
Structured-Interview Guide frequently.
All interviews were conducted in accordance with a struc-
tured-interview guide, to ensure that all topics of interest were
covered during the interview (Table). The interview guide Advantages of hand hygiene compliance. Participants men-
was developed a priori on the basis of the constructs included tioned that prevention of cross-infections is the main advan-
in an established behavioral determinants model known as tage of hand hygiene. Participants in all 3 groups distin-
the Theory of Planned Behavior.21 Therefore, the interview guished between preventing cross-infections among patients
guide aimed to explore attitudes (ie, perceptions of different and protecting themselves. Physicians mainly mentioned the
positive and negative consequences of hand hygiene com- protection of the patient on both individual and ward level
pliance), subjective norms (ie, the perceived opinion of others as important advantages of hand hygiene, whereas nurses and
concerning hand hygiene compliance), and perceived behav- medical students primarily mentioned self-protection. Fur-

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poor hand hygiene during hospitalization 417

thermore, physicians and nurses mentioned the advantages [comments by a physician]). All participants agreed that cre-
of uniformity in procedure for the hospital as a whole. ating a stronger social norm and establishing more explicit
If participants were asked to provide reasons for perform- social control would be important for improving hand hy-
ing hand hygiene, the most frequently given reasons were the giene compliance.
protection of oneself from cross-infection (Yes, I think that
most people do it for themselves. Otherwise, you wouldnt Perceived Behavioral Control
feel the urge to wash your hands so quickly after that diabetic Barriers to hand hygiene compliance mentioned by partici-
foot [comments by a medical student]) and the need to feel pants were the occurrence of emergent situations, the lack of
clean and fresh after performing tasks perceived as dirty, such availability of and easy access to hand hygiene materials, the
as contact with body fluids or with patients or body parts lack of time, and forgetfulness. Furthermore, improving the
perceived as unclean (I think that when youve touched a availability and accessibility of materials and nonirritating
patient who was a bit sticky, you want to get rid of it [com- hand alcohol rubs were mentioned as important facilitators
ments by a physician]). All participants mentioned that they to improve compliance. Physicians reported that the scarcity
were most likely to perform hand hygiene when they felt that of evidence-based research supporting the role of hand hy-
their hands were dirty, before they ate, and at the end of their giene in the prevention of hospital-acquired infections is a
shift. barrier for compliance (There should be data [about the
Disadvantages of hand hygiene compliance. The disadvan- effectiveness of hand hygiene], real data, presentations, and
tages participants specified as being associated with perfor- reports so that people can read about it [comments by a
mance of hand hygiene, mainly dryness and soreness of hands physician]).
after performance of hand hygiene, were similar among all
3 groups. Furthermore, physicians and nurses mentioned the discussion
amount of time necessary for adequate hand hygiene.
With the help of a qualitative study design, we analyzed the
Subjective Norms behavioral determinants of hand hygiene compliance among
different hospital healthcare workers, including physicians,
Social control. All participants mentioned a lack of social nurses, and medical students. The hand hygiene behavior of
control with regard to compliance with hand hygiene guide- healthcare workers appears to be motivated by self-protection
lines, and all groups reported difficulties in addressing others and a desire to clean oneself after a task that is perceived to
about their hand hygiene behavior (I think lots of people be dirty. Nurses and medical students expressed the impor-
see it [ie, the lack of hand hygiene], but dont say anything tance of hand hygiene for preventing cross-infection among
[comments by a medical student]). patients and themselves, whereas physicians expressed the
Role models. Nurses and particularly medical students importance of hand hygiene but also perceived a lack of evi-
mentioned the presence of negative role modelsthat is, ex- dence for the importance of hand hygiene in preventing cross-
perienced nurses or physicians who were noncompliant with infection.
hand hygiene guidelinesas reasons for their own noncom- Personal beliefs about the efficacy of hand hygiene and the
pliance. Medical students explicitly mentioned that they are examples set and norms established by senior staff in a hos-
unable to comply if the rest of the group fails to comply. pital are of major importance for hand hygiene compliance.
They would otherwise fall behind during rounds, and they Medical students tend to copy the hand hygiene behavior of
reported feeling strongly influenced by negative role models their superiors, leading to noncompliance when they observe
to abstain from compliance with hand hygiene guidelines (To noncompliance by others. Physicians mentioned that their
a great extent, I copy the behavior of the physicians and staff noncompliance was associated with a perceived lack of evi-
members [comments by a medical student]). Furthermore, dence that hand hygiene is effective in the prevention of
medical students and nurses reported that they adjust their hospital-acquired infection, which could be an explanation
behavior to match the behavior that they witness in practice for the inverse correlation found between the level of edu-
(If you arrive here and no one washes their handsyes, I cation and the rate of handwashing compliance.22
think you copy that behavior. You think thats what they do Behavioral research into hand hygiene compliance is highly
so that must be right [comments by a nurse]). Physicians needed because it is essential for developing successful mul-
also reported the need for positive role models. tifaceted interventions.8,11 A qualitative study of hand hygiene
Norms. In all groups, a discussion arose about the cul- was performed by Whitby et al.,12 although it focused more
ture in the hospital, in which it is accepted that physicians, on hand washing in the community setting and included a
particularly senior staff, deviate from the set of rules and group of participants (children, mothers, and nurses) that
guidelines, and its importance as reason for noncompliance differed from those in our study (physicians, nurses, and
(Those at the bottom of the ladder make sure that everything medical students). Despite the differences, one striking sim-
is done correctly, and then a staff member [ie, a physician] ilarity can be found in the data about nurses attitudes towards
walks in without washing his hands and everything is wasted hand washing at work. The nurses in the study by Whitby

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418 infection control and hospital epidemiology may 2009, vol. 30, no. 5

and colleagues reported that their level of compliance is in- experimental studies on the role of hand hygiene in the
fluenced by their own assessment of the degree of dirtiness prevention of cross-infection should also be conducted.
or the lack of cleanliness of a patient, which was also found When interpreting the aforementioned results, a number
in our study. This assessment results in performance of hand of limitations have to be taken into account. Different groups
hygiene mainly after direct contact with the patient. It also of healthcare workers participated in this study. However, the
indicates of a lack of knowledge about the presence of path- number of participating physicians was relatively small be-
ogens in the vicinity of the patient and on such items as door cause of the impracticality of focus group interviews for this
handles and telephones. Increased knowledge about such profession. This, in effect, generated 2 types of qualitative
pathogens, combined with the desire to feel clean, could lead data, one from group discussions and another from individual
to better hand hygiene compliance after contact with these interviews. On the other hand, the quality of the data is
inanimate objects. That hand hygiene is mainly performed strengthened by the participation of different types of health-
after patient contact is supported not only by the results from care workers and by the inclusion of healthcare workers from
the study by Whitby et al.,12 but also by numerous studies different institutions. This, in combination with the consid-
measuring hand hygiene performance in practice.16,23-27 In erable degree of consistency in the answers given, enhances
general, these studies find much higher rates of hand hygiene the generalizability of the results. It is furthermore important
after patient contact than before patient contact. This pro- to consider that the value of the findings presented here lies
vides another indication that the motivation for performing in their qualitative nature; that is, they are useful in the pre-
hand hygiene is perhaps influenced more by the inherent liminary identification of possible factors influencing hand
desire to clean oneself when feeling dirty than by an interest hygiene compliance. These factors can then be investigated
in protecting the patient, as previously suggested by Whitby further in quantitative and experimental research.
et al.12
In the same study, Whitby and colleagues further found conclusions
that elective in-hospital handwashing behavior was signif- The results of this qualitative study indicate that beliefs about
icantly influenced by the nurses beliefs about the benefits of the importance of self-protection are the main reasons for
the activity, by peer pressure from senior physicians and ad- performing hand hygiene. Lack of positive role models among
ministrators, and by role modeling. Pittet et al.28 performed and social norms established by senior physicians may hinder
a quantitative study among physicians and found that ob- compliance.
served physician adherence was mainly predicted by variables The results from this study should inform methods for
related to the environmental context, to social pressure and stimulating hand hygiene compliance in healthcare settings.
the perceived risk of cross-transmission, and to a positive If hand hygiene is indeed mainly influenced by the desire to
individual attitude toward hand hygiene. The results pre- clean oneself and by the behavior of other healthcare pro-
sented in both studies confirm our results and underline the fessionals, then workshops and courses that focus on patient
importance of social norms and culture for compliance with protection may have little effect. The best methods for im-
hand hygiene guidelines. Physicians mentioned a need for proving hand hygiene compliance may involve encouraging
more social control to improve their hand hygiene behavior, senior healthcare workers to be compliant and creating a
although it remains unclear who should provide this control. supportive environment with readily available and easily ac-
Most physicians do not feel inclined to comment on the hand cessible hand hygiene facilities.
hygiene behavior of their colleagues, and some feel that nurses
should perform this task. However, only a few nurses (mostly acknowledgments
older, more-experienced nurses) mentioned ever having com-
mented on the hand hygiene behavior of physicians. Fur- We thank Meeke Hoedjes and Tinneke Beierens, for their help during the
focus groups interviews, and all healthcare workers who participated in this
thermore, medical students appear to copy the hand hygiene study.
behavior of the physicians they see at work, often resulting Financial support. This project was funded by ZonMW (grant 2430-
in poor hand hygiene habits that will, in turn, be copied by 0036). The funding source had no involvement in the study and the authors
future students. Positive role models are essential in breaking work is independent.
Potential conflicts of interest. All authors report no conflicts of interest
the cycle.2 However, most physicians do not see themselves
relevant to this article.
as role models, and many appear to be uninclined to change
their behavior. Authorities responsible for medical training
Address reprint requests to V. Erasmus, MSc, Department of Public Health,
of physicians in all career phases should be involved in pro- University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam,
moting better hand hygiene compliance, because doing so the Netherlands (
may improve compliance across the hierarchy of healthcare
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