Major Articles
Understanding adherence to hand hygiene recommendations: The theory of planned behavior*,**

Portions of this paper were presented at the 1998 annual meeting of the Association for Professionals in Infection Control in Baltimore, Md.
https://doi.org/10.1067/mic.2001.18405Get rights and content

Abstract

Background: Most health care workers (HCWs) are aware of the rationale for hand hygiene procedures, yet failure to adhere to guidelines is common. Little is known about factors that motivate HCWs to practice hand hygiene. Purpose: The purposes of this study were to (1) estimate adherence to hand hygiene recommendations; (2) describe relationships among motivational factors, adherence, and intensity of nursing unit activity; and (3) test an explanatory model for adherence to hand hygiene guidelines based on the theory of planned behavior (TPB). Method: A longitudinal, observational design was used to collect data from 120 registered nurses employed in critical care and postcritical care units. Nurses provided information about motivational factors and intentions and a self-report of the proportion of time they followed guidelines. At least 2 weeks later, the nurses' hand hygiene performance was observed while they provided patient care. Structural equation modeling was used to test the TPB-based model. Results: Rate of adherence to recommendations for 1248 hand hygiene indications was 70%. The correlation between self-reported and observed adherence to handwashing recommendations was low (r = 0.21). TPB variables predicted intention to handwash, and intention was related to self-reported hand hygiene. Intensity of activity in the nursing unit, rather than TPB variables, predicted observed adherence to hand hygiene recommendations. Conclusions: The limited association between self-reported and observed hand hygiene scores remains an enigma to be explained. Actual hand hygiene behavior may be more sensitive to the intensity of work activity in the clinical setting than to internal motivational factors. (Am J Infect Control 2001;29:352-60.)

Section snippets

Setting

Intensive care and postintensive care units are settings in which hand hygiene is especially important because patients are vulnerable to nosocomial infections. Severity of their illnesses, presence of a high number of invasive devices, and frequent physical contact with caregivers are common risk factors. From July 1996 through October 1997 data were collected on hand hygiene practices and attitudes of nurses toward hand hygiene. These nurses worked in adult medical/surgical intensive care

Results

Hand hygiene observation was completed for all enrolled participants (70 critical care and 50 postcritical care nurses). Nurses were observed on all shifts: 69 (57%) during the day, 26 (22%) during the evening, and 25 (21%) at night. Observation time for the entire study totaled approximately 215 hours; most observation periods (n = 80; 66%) lasted 61 to 120 minutes.

Discussion

Hand hygiene is acknowledged to be a fundamental practice in providing safe health care to patients; however, the motivational issues involved in adherence to guidelines have not been elucidated. Progress in explaining and understanding variation in adherence to hand hygiene recommendations has been impeded by lack of a theoretical perspective. Intervention studies with a cognitive focus designed primarily to increase HCW knowledge about handwashing have generally been unsuccessful at improving

Acknowledgements

We wish to thank Laura Duckett, PhD, RN, for her invaluable support and guidance. We also thank Sharon Ridgeway, PhD, RN, and Nancy Van Drunen, BS, RN, for assistance with data collection.

References (33)

  • C. O'Boyle

    Variables that influence health care workers' adherence to recommended handwashing practices [dissertation]

  • PM Dubbert et al.

    Increasing ICU staff handwashing: effects of education and group feedback

    Infect Control Hosp Epidemiol

    (1990)
  • JA Mayer et al.

    Increasing handwashing in an intensive care unit

    Infection Control

    (1986)
  • EL Larson et al.

    An organizational climate intervention associated with increased handwashing and decreased nosocomial infections

    Behav Med

    (2000)
  • I. Ajzen

    Attitudes, personality and behavior

    (1988)
  • I. Ajzen

    A theory of planned behavior

  • Cited by (327)

    • Impact of Training on Employees’ Handwashing Behaviors in School Nutrition Programs

      2023, Journal of the Academy of Nutrition and Dietetics
      Citation Excerpt :

      Normative beliefs contributed significantly to predicting subjective norms during all phases for both the control and experimental groups. Research using the theory of planned behavior has found similar results.14,17,18,20-22,35,47,48 Participants identified the following main barriers (control beliefs) for properly washing their hands: lack of access to equipment (more handwashing sinks) and emphasizing the importance of having all the resources needed for employees to properly wash their hands.

    View all citing articles on Scopus
    *

    Supported in part by grants from the Georgetown University School of Nursing, the 3M Enrich Program, and the Association of Professionals in Infection Control Research Foundation.

    **

    Reprint requests: Carol A. O'Boyle, PhD, RN, Assistant Professor, School of Nursing, 6-101 Weaver-Densford Hall, University of Minnesota, 308 Harvard St, SE, Minneapolis, MN 55455-0342.

    View full text