infection control and hospital epidemiology may 2009, vol. 30, no. 5
o r i g i n a l a r t i c l e
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
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
Hospital-acquired infections are a major threat to patients and place a great burden on national healthcare services.1,2 This problem must be combated with an adequate level of hand hygiene compliance, which is of crucial importance in pre- venting cross-transmission3-5 and has been identified as a health policy priority.1,6 However, the level of hand hygiene compli- ance remains low worldwide, and it was termed “unacceptably poor” by a public health authority in London, United King- dom.7 Interventions aimed at improving hand hygiene com- pliance have been implemented, but the effects of these inter- ventions remain modest and/or of short duration.8,9 To develop interventions with more-pronounced and sustainable effects, information is needed on the behavioral determinants of hand hygiene compliance.10 This topic has only recently started re- ceiving attention by investigators involved in hand hygiene
research.11,12 Qualitative research can provide valuable insight into possible behavioral determinants13,14 and is often the first step in a stepwise approach to intervention development.15
Qualitative methods have, however, rarely been used to evaluate hand hygiene compliance among healthcare workers. Com- pliance with hand hygiene among different groups of hospital workers may be influenced by beliefs and norms that vary across the groups. Review of the international literature reveals that the hand hygiene behavior of nurses has been studied most extensively.16,17 Physician compliance is often found to be lower than that of nurses,18,19 although the reason for this is not always clear. Medical students’ hand washing behavior has rarely been studied,20 although research into their behavior could provide essential knowledge on how tomorrow’s phy- sicians could be stimulated to comply with hand hygiene guide-
