Background
Term | Explanation |
---|---|
Hand hygiene improvement strategy
| An HH improvement strategy is composed of a number of components intended to change HH behaviour. These various components work best together and support each other in targeting potential barriers to appropriate HH. |
Strategy component
| A strategy component refers to the specific method used to address a potential barrier to appropriate HH. |
Examples: education, reminders, performance feedback, social influence, leadership, setting norms and targets. | |
Improvement activities
| Improvement activities refer to the operationalization of strategy components. |
Examples: educational website, bar charts of HH rates, posters, ward manager addresses barriers to enable HH as recommended, provision of alcohol-based hand rub. | |
Intention-to-treat analysis
| The intention-to-treat analysis in our study was an analysis based on the initial treatment intent. In this, wards were analysed according to the group (experimental or control) to which they were originally allocated, regardless of whether they actually received the improvement strategy and despite the fact that there may be less impact on those who did not receive the intervention |
As-received analysis
| The as-received analysis in our study is based on the treatment actually received. In this, wards were analysed according to improvement strategy actually received, regardless of their allocation. |
The case of hand hygiene: the HELPING HANDS study
Theory | Focus | Key elements |
---|---|---|
Social learning theory [26] | Behaviour is learned from the environment through the process of observational learning. | – Demonstration, role modelling. |
– Encompasses attention, memory, and motivation. | ||
Social influence theory [27] | Social norm in a network determines what correct behaviour is. | – Norm and target setting. |
– Commitment team members. | ||
– Use of opinion leaders. | ||
– Performance feedback. | ||
– Team members address each other in case of undesirable behaviour. | ||
Orientation on team climate and willingness to change | – Team Vision: clarity, perceived value, and attainability. | |
– Participation Safety: decision-making, information sharing, interaction and safety. | ||
– Support for Innovation: articulated and enhanced support. | ||
– Task Orientation: commitment to excellence, appraisal and task orientation. | ||
Theories of leadership [30] | Leading, coaching and managing a team | – Active commitment/participation in performance improvement initiatives. |
– Setting norms and targets/direction/expectations. | ||
– Encouragement and support/motivate staff. | ||
– Monitoring performance and feedback. |
State-of-the-art strategy | Team and leaders-directed strategy |
---|---|
Education
|
All elements of the state-of-the-art strategy
|
Distribution of educational material/ written information (leaflet) about HH that contained: | • Education, reminders, feedback, facilities and products, see above |
• The importance of HH |
Setting norms and targets within the team
|
• Misconceptions about alcohol-based HH disinfection | • Three interactive team sessions (1 h-1.5 h each) that included goal setting in HH performance at group level. Team sessions were guided by the team manager and a external coach. |
• Theory and practical indications for the use of HH | ◦ Exploring nurses’ knowledge and perception of current HH behaviour (individual- and team level) and discussing actual HH compliance rates |
◦ Transition from individual responsibility to a shared team responsibility | |
• Educational material/ written information about HH | ◦ Creating a participatory and non-threatening climate for team interaction |
• Knowledge quiz with feedback. Visitors could test their knowledge about HH | ◦ Commitment to high standards of HH performance |
• The nursing ward with the highest number of visitors to the website was rewarded | ◦ Defining and documenting improvement activities |
Educational sessions on prevention of hospital acquired infections | • Analysis of barriers and facilitators to determine how nurses could best adapt their behaviour in order to reach their goal. |
• Launching hospital-wide campaign with practical demonstrations of HH | • Nurses address each other in case of undesirable HH behaviour |
Reminders
|
Gaining active commitment and initiative of ward management
|
• Distribution of posters that emphasised the importance of HH, particularly alcohol-based hand disinfection. Posters were displayed in several strategic areas within the units and replaced by another poster after 12 weeks. | • Ward manager designated HH as a priority |
• Interviews and messages in newsletters or hospital magazines | • Ward manager actively supported team members and informal leaders |
• General reminders by opinion leaders/ ward management | • Ward manager discussed HH compliance rates with team members |
Feedback
|
Modeling by informal leaders at the ward
|
• Bar charts of HH rates of every nursing ward were sent to the ward manager twice. This also included a comparison of ward performance and hospital performance | • Informal leaders demonstrated good HH behaviour |
Facilities and products
| • Informal leaders modeled social skills of team members in addressing HH behaviour of colleagues |
• Screening and if necessary adapt products and appropriate facilities | • Informal leaders instructed and stimulated their colleagues in providing good HH behaviour |
Methods
Setting and participants
Measurements and data collection
Effect evaluation
Effects on nurses’ HH compliance
Process evaluation
Adherence to the improvement strategies as planned
Contextual factors
Nurses’ experiences with specific components of the improvement strategies
Statistical analyses
Effect evaluation
Effects on nurses’ HH compliance: intention-to-treat versus as-received analysis
Process evaluations linked to effectiveness evaluations
Analysis of adherence to the improvement strategies and related changes in HH compliance
Analysis of contextual factors and related changes in HH compliance
Analysis of nurses’ actual experiences with specific components of the improvement strategies and related changes in HH compliance
Results
General
Ward characteristics | SAS†
|
n=47
| TDS‡
|
n=20
|
---|---|---|---|---|
Hospital
| University based hospital |
n=16
| University based hospital |
n=9
|
General hospital A |
n=15
| General hospital A |
n=5
| |
General hospital B |
n=16
| General hospital B |
n=6
| |
Specialism
| Surgical ward |
n=14
| Surgical ward |
n=7
|
Medical ward |
n=16
| Medical ward |
n=8
| |
Intensive care unit |
n=12
| Intensive care unit |
n=1
| |
Paediatric ward |
n=5
| Paediatric ward |
n=4
|
Effect evaluation
Effects on nurses’ HH compliance: intention-to-treat versus as-received analysis
Intention-to-treat analysis | T1 | T2 | T3 |
---|---|---|---|
baseline | post intervention | follow-up | |
Strategy SAS†
| 21.8% (37 wards) | 40.4% (37 wards) | 45.9% (37 wards) |
Δ T1-T2 18.6% | Δ T1-T3 24.1% | ||
Strategy TDS‡
| 19.1% (30 wards) | 53.1% (30 wards) | 52.1% (30 wards) |
Δ T1-T2 34.0% | Δ T1-T3 33.0% | ||
Groups compared | |||
TDS vs. SAS |
f=0.465 |
f=19.409 |
f=1.781 |
ANOVA |
p=0.498 |
p=0.000** |
p=0.187* |
As-received analysis
|
T1
|
T2
|
T3
|
baseline | post intervention | follow-up | |
Strategy SAS†
| 21.5% (47 wards) | 40.7% (47 wards) | 44.1% (47 wards) |
Δ T1-T2 19.2% | Δ T1-T3 22.6% | ||
Strategy TDS‡
| 20.7% (20 wards) | 58.6% (20 wards) | 59.5% (20 wards) |
Δ T1-T2 37.9% | Δ T1-T3 38.8% | ||
Groups compared | |||
TDS vs. SAS |
f=0.001 |
f=40.304 |
f=10.187 |
ANOVA |
p=0.978 |
p=0.000** |
p=0.002** |
Groups compared | |||
SAS groups randomised to TDS (n=10) vs SAS groups randomised to SAS (n= 37) |
p=0.322 |
p=0.650 |
p=0.224 |
T-test |
Process evaluations linked to effectiveness evaluations
Adherence to the improvement strategies and related changes in HH compliance
Impact of variation in adherence to the components of the state-of-the-art strategy (n = 67)
Impact of variation in adherence to the additional components of the team and leaders-directed strategy (n = 20)
Contextual factors and related changes in HH compliance
Δ HH compliance T1 to T2 | Δ HH compliance T1 to T3 | |||||
---|---|---|---|---|---|---|
Variable | B |
SE B | β | B |
SE B | β |
Constant | 27.78 | 6.32 | 47.74 | 7.78 | ||
Baseline T1 | -.91 | .94 | -.80**
| -.69 | .12 | -.64**
|
Strategy | 17.29 | 2.61 | .45** | 13.47 | 3.21 | .36** |
Hospital | -.3.92 | 1.66 | -.19* | -.12.17 | 2.03 | -.60** |
Specialism | .72 | 1.28 | .04 | .41 | 1.60 | .03 |
R
2
| .70 | .51 | ||||
F for change in R
2
| 39.83** | 18.18** |
Nurses’ experiences with the improvement strategies and related changes in HH compliance
Correlation with changes in HH compliance in all study groups | ||
---|---|---|
Component
| Δ T1 to T2 | Δ T1 to T3 |
Proposition
|
S rho (p value) |
S rho (p value) |
Performance feedback
| .315 (.015*) | .347 (.007**) |
I do know my ward’s HH performance. | ||
Social influence
| .381 (.003**) | |
My colleagues support each other in performing HH. | ||
Our team members address each other in case of undesirable HH behaviour. | .414 (.001**) | |
Leadership
| .293 (.025*) | |
My manager pays regular attention to the adherence of HH guidelines. | ||
HH is not a priority at our ward. | .261 (.046*) | |
My ward manager addresses barriers to enable HH as recommended. | .319 (.014*) | |
My ward manager holds team members accountable for HH performance. | .382 (.003**) | |
My ward manager encourages and motivates our team members to perform HH. | .352 (.006**) | |
Correlation with changes in HH compliance within SAS
†
| ||
Education
| -.315 (.042*) | |
I know exactly when to perform HH. | ||
Leadership
| .387 (.011*) | |
My ward manager encourages and motivates our team members to perform HH. | ||
My ward manager holds team members accountable for HH performance. | .398 (.009**) | |
Social influence
| . | |
Our team members address each other in case of undesirable HH behaviour. | .347 (.025*) |