WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE
Elective community behaviour has been shown to have a major
impact on nurses with regard to their intention to undertake
elective in-hospital hand cleansing. Other important facilitators
of nurses electing to practise hand hygiene are attitude and
an expectation of compliance not by their nursing peers, but
by doctors and administrators. 725 Nurses and doctors were
more likely to report high levels of compliance if they believed
that their own peer group also complied. 732 Reduction in
effort required to undertake hand hygiene has no influence
on inherent hand hygiene behaviour and only minimal impact
on elective hand hygiene intent. 725 Yet, the strongest predictor
of self-reported compliance by nurses and doctors who had
previously been exposed to hand hygiene campaigns was
the belief that the practice was relatively easy to perform. 732
Hand hygiene behaviour considered as being relatively easy
to perform is likely to be elective hand hygiene opportunities.
Whether the hand hygiene opportunity the HCW is presented
with is elective or inherent, the primary motivator to undertake
it is self-protection. 725 Therefore, future cognitive programmess
aiming to modify HCWs’ hand hygiene behaviour should
consider adjusting the benefits to include self-protection and
patient protection.
The nursing behaviour model predicts a positive influence
by senior administrators and doctors on the hand hygiene
compliance of nurses but, surprisingly, there was no influence
by senior nurses on junior nurses. Lankford and colleagues 802
found that poor hand hygiene practices in senior medical and
nursing staff could provide a negative influence on others, while
Pittet and colleagues 335 reported that doctors’ perception of
being role models to other colleagues had a positive influence
on their compliance, independent of system constraints and
hand hygiene knowledge.
All influences in the model for nursing hand hygiene behaviour 725
act independently of behavioural intent. This suggests that
the effective component of the Geneva programme, 60 which
has demonstrated significantly improved and sustained hand
hygiene compliance over a period of several years. 60,490 was
not only the introduction of an alcohol-based handrub per se,
but were those components of the programme that directly
promoted the desired behaviour: peer support from high-level
hospital administrators and clinicians 789 and the perception that
one’s colleagues’ adherence behaviour was good. 732
Results of a behaviour modification at an organizational level
further support these conclusions. Larson and colleagues 713
described a significant increase in handwashing compliance in a
teaching hospital sustained over a 14-month period. The focus
of this behaviour-based programme was directed to induce an
organizational cultural change towards optimal handwashing
with senior clinical and administrative staff overtly supporting
and promoting the intervention.
The dynamic of behavioural change is complex and
multifaceted. 60,713,725,789 It involves a combination of education,
motivation, and system change. 789 Wide dissemination of hand
hygiene guidelines alone is not sufficient motivation for a change
in hand hygiene behaviour. 728 With our current knowledge, it
can be suggested that programmes to improve hand hygiene
compliance in HCWs cannot rely solely on awareness, but must
take into account the major barriers to altering an individual’s
pre-existing hand hygiene behaviour.
18.2.1 Factors influencing behaviour
Patterns of hand hygiene behaviour are developed and
established in early life. As most HCWs do not begin their
careers until their early twenties, improving compliance means
modifying a behaviour pattern that has already been practised
for decades and continues to be reinforced in community
situations.
Self-protection: this is not invoked on a true microbiological
basis, but on emotive sensations including feelings of
unpleasantness, discomfort, and disgust. These sensations are
not normally associated with the majority of patient contacts
within the health-care setting. Thus, intrinsic motivation to
cleanse hands does not occur on these occasions.
18.2.2 Potential target areas for improved compliance
Education. While HCWs must be schooled in how, when
and why to clean hands, emphasis on the derivation of their
community and occupational hand hygiene behaviour patterns
may assist in altering attitudes.
Motivation. Influenced by role modelling and perceived
peer pressure by senior medical, nursing, and administrative
staff, motivation requires overt and continuing support
of hand hygiene as an institutional priority by the hospital
administration. 789 This will, in due course, act positively at both
the individual and organizational levels. Such support must
be embedded in an overall safety climate directed by a toplevel
management committee, with visible safety programmes,
an acceptable level of work stress, a tolerant and supportive
attitude towards reported problems, and a belief in the efficacy
of preventive strategies.
Reinforcement of appropriate hand hygiene behaviour
Cues to action such as cartoons and even alcohol-based rub
itself appropriately located at the point of care should continue
to be employed.
Patient empowerment. While involvement of patients in hand
hygiene programmes for HCWs has been demonstrated to be
effective 803-806 and also incorporated in a national programme, 807
one campaign found less than a third of patients and public
wanted to be involved. 808 Further study of the approach
of engaging the public is required before its widespread
application will result in acceptance. Possible obstacles to be
addressed include cultural constraints, the barrier of patient
dependency on caregivers, and the lack of applicability of this
tactic to ventilated, unconscious and/or seriously ill patients
who are often at most risk of cross-infection. 656 Furthermore,
whether patients reminding HCWs that they have to clean their
hands before care would interfere with the patient–caregiver
relationship remains to be properly assessed in different
sociocultural and care situations.
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