Abstract
Despite widespread education and knowledge regarding the effectiveness of hand hygiene in the prevention of infections, hand hygiene compliance rates of healthcare workers remain at less than 100%. A clinical question has been developed for this review: is a strong marketing campaign more effective than standard education in improving staff hand hygiene compliance rates in a hospital setting? The Cochrane database, Medline, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched. Quantitative studies related to intervention effectiveness on hand hygiene compliance rates, as well as qualitative studies analyzing perceptions and beliefs related to hand hygiene adherence were included in this review. Six studies and one national guideline were evaluated for evidence-based guidelines related to this clinical question. The literature review revealed that a multidisciplinary, multimodal campaign with an educational component is an effective strategy to increase hand hygiene adherence. Furthermore, risk factors related to noncompliance were identified. Future research should focus on improvement in the quality of evidence, specifically through the addition of randomized controlled trials, as well as upon the sustainability of any hand hygiene intervention.
Evaluation of Methods to Improve Hand Hygiene Compliance
In the United States, hospital acquired infections (HAIs) occur at a rate of almost two million per year (Centers for Disease Control and Prevention [CDC], 2011). These infections place an enormous burden upon the patient, hospital, and healthcare system by leading to increased costs, length of stay, morbidity, and mortality (Graves, 2004). The CDC (2011) states that hand hygiene plays a vital role in the prevention of infection and the spread of disease. By virtue of their close contact with patients, healthcare workers logically are presented with multiple opportunities to prevent the transmission of disease by performing appropriate hand hygiene. Although education regarding hand hygiene is widespread in schools and healthcare organizations, compliance rates are still less than 100%.
The administrative team at a local pediatric hospital has deemed that improving staff hand hygiene compliance will be a top administrative goal for the upcoming year. A committee was formed to develop and implement a strategy to achieve this goal. A nurse educator volunteers for the committee, and wonders what interventions would be most successful to improve hand hygiene adherence rates with hospital staff. Specifically, the nurse educator ponders the differences in effectiveness of a strong marketing campaign versus standard education. Therefore, this paper aims to present a review of the literature evidence regarding the effectiveness of a marketing campaign as compared to a standard education intervention to improve staff hand hygiene compliance in a hospital setting.
Literature Search
A search of the literature was performed utilizing the criteria guidelines of patient, intervention, comparison, outcome, and time (PICOT) that were developed from the clinical question. The keywords of hand hygiene and compliance were derived from the PICOT. Multiple databases were searched utilizing the keywords and Boolean operators, including the Cochrane database, Medline, and the Cumulative Index to Nursing and Allied Health Literature, (CINAHL). The resulting articles were reviewed, and six articles were deemed appropriate to the clinical question at hand.
Literature Review
A systematic review was performed in 2011 to assess the effectiveness of various interventions and strategies on hand hygiene compliance. Four studies met the inclusion criteria. However, the heterogeneity of the included studies did not allow for a pooled sample size, as the methods, design, and outcome variables were so varied. Two of the studies utilized an educational approach to increasing hand hygiene compliance, with a comparison of baseline measurements to those at three to four months post intervention. Each of these studies compared a control group with the experimental group receiving the education. One study (n = 49 nurses) showed a significant increase in the percentage of nurses who exhibited appropriate hand hygiene before (p < 0.001) and after (p < 0.05) patient contact, following the education. The other study included a sample of four nursing units and did not show a significant difference in hand hygiene compliance following the education. The third and fourth studies were interrupted time series analyses. The third study revealed an increased use of alcohol-based hand rub following a marketing campaign (p < 0.0001) when compared to baseline data. The fourth study also analyzed product use following two separate multi-modal campaigns. Both the ‘Geneva’ (IRR = 1.56, 95% CI = 1.29 – 1.89, p < 0.001) and the ‘Washington’ (IRR = 1.48, 95% CI = 1.20 – 1.81, p < 0.001) campaigns showed significant increases in volume use of product. Of note, the Washington initiative showed sustained hand hygiene compliance over a two year period. Although the systematic review authors determined that a clear conclusion regarding the effectiveness of the studied interventions on hand hygiene compliance could not be drawn, they also stated that the “findings should not be taken to suggest that attempts to promote hand hygiene compliance or reduce HAIs are not worth undertaking” (Gould, Moralejo, Drey, & Chudleigh, 2011, p. 10).
In 2004, Won and associates published a study that aimed to implement and evaluate the effects of a hand washing program on hand hygiene compliance in a neonatal intensive care unit (NICU). They also studied the rates of nosocomial infections in the NICU at baseline and throughout the campaign. The study design was an open trial, with no randomization or control group. The sample was an unknown number of multi-disciplinary healthcare workers in a 24-bed level III NICU in Taiwan, including physicians, nurses, respiratory therapists, social workers, and other patient care workers. After baseline hand hygiene compliance data was collected, a multimodal campaign that included education, marketing, financial incentives and penalties, and praise was implemented. Anonymous hand hygiene observations were conducted during 312 observation periods by nurses on the NICU over a period of two years. The authors stated that hand hygiene compliance improved from 43% to 80% following the intervention, although hard data concerning numbers of healthcare workers observed in compliance versus not in compliance was not presented. Although the total number of HAIs decreased during the hand hygiene campaign, not all types of infections were statistically correlated to the improved hand hygiene compliance. However, nosocomial infections of the respiratory track were significantly associated with the improved adherence to hand hygiene (p = 0.002, r = -0.385) (Won et al., 2004).
Another study evaluating the effects of a hand hygiene intervention was published in 2011 by van den Hoogan and colleagues. This study took place in a level III NICU, with a convenience sample of all healthcare workers who came into direct patient contact in this NICU. The purpose of the study was to implement a multimodal hand hygiene campaign and evaluate its effectiveness upon hand hygiene compliance. A baseline assessment was performed over a three month period, evaluating hand hygiene adherence via direct observation. Five NICU nurses were trained to perform these direct observations, and sufficient interobserver reliability was achieved (k = 0.85). Immediately following a direct observation during the baseline assessment period, the observer would give a questionnaire to the healthcare worker that had been observed. The authors state that the questionnaire had been validated in a prior study and that reliability was established in a pilot study, but no further information or statistics are provided. The questionnaire assessed the healthcare workers knowledge related to hand hygiene and its current related protocols, as well as awareness of being observed. Following the baseline assessment period, a multimodal hand hygiene intervention was implemented. The intervention included education related to the results of current surveillance cultures, current antibiotic resistance information, results of the baseline assessment, video scenarios of problems and issues identified during the baseline period, posters showcasing good hand hygiene, and enhanced hand hygiene information in orientation. Six months after the initiation of the intervention, another three-month period of direct observations and questionnaires followed. Data analysis revealed a significant improvement (p < 0.001) for compliance during all identified hand hygiene opportunities, from 23% at baseline to 50% after the intervention. The questionnaires revealed that the most common reasons for inadequate hand hygiene compliance were a heavy workload, understaffing, skin breakdown, forgetfulness, and the opinion that glove use negated the need for hand hygiene in certain instances. Of note, significantly more respondents acknowledged an awareness of being observed at the second assessment (44.2%) when compared to the baseline period (11.9%, p < 0.001) (van den Hoogen et al., 2011).
Whereas the above studies utilized quantitative methods to review aspects of hand hygiene compliance, Barrett and Randle (2008) conducted an interpretative, phenomenological qualitative study to investigate the perceptions of nursing students on hand hygiene practices in a clinical environment. Specifically, the authors aimed to research the factors that affect compliance and to make recommendations for future hand hygiene practice and education. The convenience sampling consisted of ten nursing students in the United Kingdom, who participated in in-depth interviews for data collection. The semi-structured interviews utilized open-ended questions and were audio-taped, analyzed, and coded for thematic content. Analysis of the interview data revealed two themes: barriers to hand hygiene compliance and fitting in. The barriers to hand hygiene revealed several sub-themes, namely lack of time due to a heavy assignment and workload, the nature of the specific procedure requiring hand hygiene, the effect of hand washing on pre-existing skin conditions, knowledge deficit related to hand hygiene recommendations, and glove use as an alternative to hand hygiene. The theme of fitting in encompassed the influence that other healthcare workers exerted over the hand hygiene practices of the nursing students sampled (Barrett & Randle, 2008). For example, the nursing students might not challenge a staff member with relationship to appropriate hand hygiene for fear of causing conflict, leading to a perceived inability to be accepted as part of the team.
Conversely, research performed in 2004 sought to identify the beliefs and perceptions of physicians related to hand hygiene, and to assess risk factors for noncompliance. One hundred sixty-three physicians from a variety of medical specialties participated in this cross-sectional study, which was performed in a large university hospital setting in Switzerland. Each physician was first directly observed during patient care in the clinical setting for hand hygiene compliance during any predetermined hand hygiene opportunities. Before the study began, the researchers had defined these opportunities and organized them into three categories as opportunities at high risk, medium risk, and low risk for cross-contamination. The observers participated in a validation pilot prior to the study, and interrater agreement was high (k=0.94). When the observation period was completed for a physician, they were given a self-report questionnaire to complete. This questionnaire was based upon social cognitive theories as applied to health behaviors, and utilized a seven point Likert scale to answer questions related to intentions, perceptions, and attitudes regarding hand hygiene. Answers were analyzed using logistical regression. The outcome of hand hygiene compliance during direct observations was found to be 57%. When analyzed according to medical specialty, the results varied greatly anywhere from 23% for anesthesiologists to 87% for internists. Of note, hand hygiene compliance was higher at 61% among those physicians who were aware of being observed (OR = 2.24, 95% CI = 1.35 to 3.74), when compared to those not aware (44%). Other factors related to an increase in adherence to hand hygiene included a positive attitude toward hand hygiene, specifically after patient contact (OR = 3.98), easy access to hand-rub solution (OR = 2.35), and the belief of being a role model for others (OR = 1.85). Several factors were identified as having a negative correlation to hand hygiene compliance, such as a busy workload and activities that were considered a high risk for cross-contamination. Furthermore, certain technical medical specialties were at a higher risk for noncompliance, such as anesthesiology, surgery, emergency, and intensive care (Pittet et al., 2004).
Most recently, Scheithauer and associates (2011) conducted a study to provide definition to hand hygiene opportunities and to assess hand hygiene compliance rates with regard to patient population, profession of caregiver, and indication for hand hygiene. This prospective observational study was performed in the pediatric intensive care unit (PICU) and NICU of a tertiary care center. The sample included an unreported number of nurses and physicians caring for the patients on these units during a 192-hour observation period. Hand hygiene opportunities were defined according to the five indications per the World Health Organization, and hand hygiene activities in relationship to these indications and the profession of the caregiver where recorded during the observation period by one observer. Observation periods were each two hours in length, with the observer monitoring the hand hygiene activities of all caregivers for two particular patients at a time. The hospital’s standardized documentation sheet for hand hygiene was utilized, and no reports of validity or reliability were included. Usage of alcohol-based hand-rub solution was also calculated based upon the spending records of the ICUs. An industry standard of three milliliters per hand washing was determined to represent an average hand hygiene opportunity. Results indicated that there were more hand hygiene opportunities on the PICU (321 per patient-days) than the NICU (194 per patient days). When calculated in accordance with volume of hand-rub solution used, the researchers determined that the healthcare workers in the NICU (61%) were significantly more compliant with hand hygiene than those in the PICU (53%, p = 0.023). When comparing professions, the compliance rates of PICU nurses (57%) was significantly higher (p < 0.001) than that of physicians (29%). The same statistical significance was found in the NICU (p = 0.017), with nurses showing more compliance (66%) than physicians (52%). In both the NICU and the PICU, adherence rates were found to be higher before patient contact and before aseptic activities (NICU – 78%, PICU – 61%) when compared to opportunities after patient contact, body fluids, or contact with patient’s surroundings (NICU – 57%, PICU – 54%). However, these results revealed a level of statistical significance in the NICU only (p < 0.001), not the PICU (p = 0.517) (Scheithauer et al., 2011).
Synthesis of the Evidence
The evidence from these studies greatly adds to the body of knowledge surrounding hand hygiene compliance. Risk factors for noncompliance have been identified and should be targeted during any hand hygiene campaign. And although education regarding the importance of hand hygiene is widespread, research has shown that knowledge deficits continue to exist. As such, any intervention to improve upon compliance should include an educational component. Moreover, the positive effect of an awareness of being observed lends itself to the promotion of a continual program for assessment and evaluation of hand hygiene compliance. In addition, research has proven that physicians are statistically more at risk for poor hand hygiene behaviors when compared to nurses. Thus a multidisciplinary approach, as opposed to a purely nursing approach, would best serve a healthcare organization.
With regards to the clinical question at hand, research has yet to prove if a marketing campaign or an educational intervention is more effective on levels of adherence. However, a multimodal approach has been shown to improve upon compliance rates and is also listed as a recommendation in the Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health-Care Settings (2002). Yet the right combination of interventions within a multimodal approach has yet to be statistically determined. Additional areas for further research would include the sustainability of a hand hygiene intervention upon compliance rates, as well as the impact of role modeling and influence upon adherence. And perhaps most importantly, future research should focus on the improvement of the quality of evidence by increasing the number of randomized controlled trials related to hand hygiene interventions.
Clinical Recommendations
Based upon the literature review, a multidisciplinary, multimodal campaign would be an appropriate approach to increasing hand hygiene compliance in a healthcare setting. This approach should contain an educational component, specifically targeting the moments when hand hygiene should be performed as well as current hand hygiene recommendations. The CDC guidelines also recommend that adherence be continually monitored, with performance feedback provided to the healthcare workers. Further suggestions include monitoring the volume of alcohol-based hand-rub use, in addition to compliance rates. Interestingly, the CDC also advocates for the inclusion of patients and families in a hand hygiene campaign as reminders for healthcare professionals. The aforementioned pediatric hospital already meets several of the CDC recommendations, namely making hand hygiene an administrative priority, auditing for hand hygiene compliance, and making alcohol-based hand-rub easily accessible in patient care areas (CDC, 2002). Keeping these suggestions in mind, the nurse educator will be well on her way to a successful hand hygiene campaign.
References
Barrett, R., & Randle, J. (2008). Hand hygiene practices: Nursing students’ perceptions. Journal of Clinical Nursing, 1851-1857. doi: 10.1111/j.1365-2702.2007.02215.x
Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Morbidity and Mortality Weekly Report, 51(RR-16), 1-48. Retrieved from http://www.cdc.gov/handhygiene/Guidelines.html
Centers for Disease Control and Prevention. (2011). Hand hygiene in healthcare settings. Retrieved February 21, 2012, from http://www.cdc.gov/handhygiene/Basics.html
Gould, D. J., Moralejo, D., Drey, N., & Chudleigh, J. H. (2011). Interventions to improve hand hygiene compliance in patient care (review). Cochrane Database of Systematic Reviews
Graves, N. (2004, April). Economics of preventing hospital infection [Online exclusive]. Emerging Infectious Diseases. Retrieved from http://wwwnc.cdc.gov/eid/article/10/4/02-0754_article.htm
Pittet, D., Simon, A., Hugonnet, S., Pessoa-Silva, C. L., Sauvan, V., & Perneger, T. V. (2004). Hand hygiene among physicians: Performance, beliefs, and perceptions. Annals of Internal Medicine, 141(1), 1-8.
Scheithauer, S., Oude-Aost, J., Heimann, K., Haefner, H., Schwanz, T., Waitschies, B., … Lemmen, S. W. (2011). Hand hygiene in pediatric and neonatal intensive care unit patients: Daily opportunities and indication- and profession-specific analyses of compliance. American Journal of Infection Control, 39, 732-737.
Van den Hoogen, A., Brouwer, A. J., Verboon-Maciolek, M. A., Gerards, L. J., Fleer, A., & Krediet, T. G. (2011). Improvement of adherence to hand hygiene practice using a multimodal intervention program in a neonatal intensive care unit. Journal of Nursing Care Quality, 26(1), 22-29.
Won, S., Chou, H., Hsieh, W., Chen, C., Huang, S., Tsou, K., & Tsao, P. (2004). Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infection Control and Hospital Epidemiology, 25, 742-746.
Appendix
Table 1
Literature Review on Hand Hygiene (HH) Compliance
Authors
Research Design
Sample
Intervention (I)/Outcome Measure (OM)
Results
Barrett & Randle (2008)
Qualitative Interpretative Design
10 nursing students in the United Kingdom
OM: Answers to semi-structured interviews with open-ended questions related to perceptions of hand hygiene compliance
Two major themes identified – barriers to hand hygiene, fear of not fitting in. Barriers theme had multiple sub-themes (time & workload, glove use, lack of knowledge, procedure type, and skin condition).
Gould et al. (2011)
Systematic Review
4 studies (1 Randomized controlled trial, 1 controlled before & after design, 2 interrupted time series studies)
I: Education, marketing campaign, initiatives
OM: Percent staff performing HH, observations of HH compliance, antibiotic use, use of hand-rub in liters
Authors unable to pool results due to differing designs and outcome measures. One educational campaign showed an increase in HH (p<0.05), another did not. Marketing campaign (p<0.0001) and HH initiative (initiative 1 IRR = 1.56, 95% CI = 1.29 – 1.89; initiative 2 IRR = 1.48, 95% CI – 1.20 – 1.81) showed increases in product use.
Pittet et al. (2004)
Descriptive Quantitative (cross-sectional survey)
163 physicians
OM: Hand hygiene compliance in clinical setting, answers to questionnaire regarding beliefs & perceptions
Hand hygiene compliance was 57% across all physicians, but varied among specialty areas. Compliance correlated positively to belief someone watching, role modeling, positive attitude, & accessibility of hand-rub. HH correlated negatively to high workload, certain clinical activities, and certain medical specialty areas.
Scheithauer et al. (2011)
Prospective observational study
Nurses and physicians (number unknown) in pediatric and neonatal intensive care units in a tertiary care center
OM: Number of HH opportunities, HH compliance rates, alcohol hand-rub usage
Number HH opportunities higher in PICU than NICU (p = 0.02). Nurse HH compliance rates higher than physician (PICU: 57% to 29%, p < 0.001; NICU: 66% to 52%, p = 0.017). Compliance rates in NICU & PICU higher before patient contact & before aseptic procedure than all other opportunities (p < 0.001 NICU, PICU not significant).
Van den Hoogan et al. (2011)
Program Analysis
Healthcare workers in a neonatal intensive care unit
I: Multimodal HH campaign including education, marketing, videos, enhanced orientation
OM: HH compliance rates, answers to questionnaire
Significant (p < 0.001) improvement for HH compliance from baseline (23%) to after intervention (50%). Identification of common reasons for noncompliance (heavy workload, skin breakdown, understaffing, forgetfulness, use of gloves).
Won et al. (2004)
Open trial
Healthcare workers (number unknown) in a level III NICU
I: Multi-modal campaign including education, marketing, praise, financial incentives & penalties
OM: Appropriate hand hygiene, rates of nosocomial infections
Compliance increased from 43% at baseline to 80% during the campaign, at the two year mark. The improved HH compliance was associated with a decrease in respiratory HAIs (p = 0.002, r= -0.385)
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