Understanding Practice: Factors That Influence Physician Hand Hygiene Compliance

Janet E. Squires, PhD; Stefanie Linklater, MSc; Jeremy M. Grimshaw, PhD; Ian D. Graham, PhD; Katrina Sullivan, MSc; Natalie Bruce, MScN; Kathleen Gartke, MD; Alan Karovitch, MD; Virginia Roth, MD; Karen Stockton, MHSc; John Trickett, BScN; Jim Worthington, MD; Kathryn N. Suh, MD

Disclosures

Infect Control Hosp Epidemiol. 2014;35(12):1511-1520.

Abstract and Introduction

Abstract

Objective To identify the behavioral determinants—both barriers and enablers—that may impact physician hand hygiene compliance.

Design A qualitative study involving semistructured key informant interviews with staff physicians and residents.

Setting An urban, 1,100-bed multisite tertiary care Canadian hospital.

Participants A total of 42 staff physicians and residents in internal medicine and surgery.

Methods Semistructured interviews were conducted using an interview guide that was based on the theoretical domains framework (TDF), a behavior change framework comprised of 14 theoretical domains that explain health-related behavior change. Interview transcripts were analyzed using thematic content analysis involving a systematic 3-step approach: coding, generation of specific beliefs, and identification of relevant TDF domains.

Results Similar determinants were reported by staff physicians and residents and between medicine and surgery. A total of 53 specific beliefs from 9 theoretical domains were identified as relevant to physician hand hygiene compliance. The 9 relevant domains were knowledge; skills; beliefs about capabilities; beliefs about consequences; goals; memory, attention, and decision processes; environmental context and resources; social professional role and identity; and social influences.

Conclusions We identified several key determinants that physicians believe influence whether and when they practice hand hygiene at work. These beliefs identify potential individual, team, and organization targets for behavior change interventions to improve physician hand hygiene compliance.

Introduction

Hand hygiene is recognized globally as a leading measure to reduce healthcare-associated infection.^[1–4] Hand hygiene compliance, however, is unacceptably low.^[5,6] Physicians in particular are repeatedly observed as being poor compliers.^[6] Promotion of hand hygiene is a complex issue.^[2] To develop interventions with more pronounced and sustainable effects, knowledge of the behavioral determinants to hand hygiene is needed.^[7] While factors related to nurses' noncompliance has been studied frequently,^[7–9] reasons for low compliance among physicians are less well understood. Studies investigating healthcare workers generally (which sometimes include a small sample of physicians) have reported a range of barriers, including environmental (eg, lack of access to sinks, difficulty of locating products, empty or broken dispensers, and time constraints) and personal (eg, attitudinal beliefs, skin irritation from repeated hand washing) barriers.^[10,11] Additional barriers specific to physicians identified or postulated include educational gaps in infection control training,^[12–14] a perception that their compliance is better than it actually is,^[15,16] a more cavalier attitude toward infection control with experience,^[17,18] a lack of positive physician role models,^[18–20] and the local (eg, unit, hospital) culture of patient safety.^[21]

We located only 1 study that explicitly used behavioral theory to study hand hygiene compliance among physicians. Erasmus et al^[7] conducted a qualitative study framed by the theory of planned behavior; findings showed that physicians felt hand hygiene was important for self-protection but that there was little evidence that handwashing is effective in preventing cross-infection. Residents/medical students also stated said that they copy the behavior of their superiors, which often leads to their noncompliance.^[7]

The purpose of this study was to identify the behavioral determinants—both barriers and enablers—to physician hand hygiene compliance at 1 tertiary care hospital. The theoretical domains framework (TDF), which is a behavior change framework, guided the study. The TDF was selected because of it comprehensiveness; it represents an agreed set of key theoretical constructs that can be used to identify all (rather than a subset) of possible barriers and enablers to healthcare professional behaviors, such as hand hygiene. The TDF was developed jointly by health psychology theorists, health services researchers, and health psychologists and comprises 14 theoretical domains derived from 128 constructs from 33 different health, behavioral, and social psychology theories that explain health-related behavior change (Table 1).^[22,23] The TDF has been used previously to successfully identify the determinants of a wide range of healthcare professional behaviors, including hand hygiene with nurses.^[9,24] This is the first application of the TDF specific to physician hand hygiene compliance.

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Abstract and Introduction
Methods
Results
Discussion
References

Table 1. Theoretical Domains Framework
Theoretical domain	Definition²²	Sample question
Knowledge	An awareness of the existence of something	Are you aware of any guidelines about hand hygiene?
Skills	An ability or proficiency acquired through practice	Were you ever trained in the proper technique for hand hygiene?
Social/professional role and identity	A coherent set of behaviors and displayed personal qualities of an individual in a social or work setting	Is hand hygiene a standard part of your patient consultations?
Beliefs about capabilities	Acceptance of the truth, reality, or validity about an ability, talent, or facility that a person can put to constructive use	How easy or difficult is it for you to practice hand hygiene? What made it easy/what made it difficult?
Optimism	The confidence that things will happen for the best or that desired goals will be attained	What do you think will happen if you are not able to practice hand hygiene?
Beliefs about consequences	Acceptance of the truth, reality, or validity about outcomes of a behavior in a given situation	What are the benefits/negative aspects when good hand hygiene is practiced?
Reinforcement	Increasing the probability of a response by arranging a dependent relationship, or contingency, between the response and a given stimulus	In the past, are there any personal or external incentives that you have experienced to be effective to improve hand hygiene?
Intentions	A conscious decision to perform a behavior or a resolve to act in a certain way	Do you intend to practice hand hygiene?
Goals	Mental representations of outcomes or end states that an individual wants to achieve	Considering your other priorities, on a scale of 1 to 10, with 10 being very important, how important do you think it is for you to practice hand hygiene?
Memory, attention, and decision processes	The ability to retain information, focus selectively on aspects of the environment, and choose between 2 or more alternatives	Is hand hygiene automatic, or do you need to remember or be reminded to do it?
Environmental context and resources	Any circumstance of a person's situation or environment that discourages or encourages the development of skills and abilities, independence, social competence, and adaptive behavior	What aspects of your work environment influence whether you practice hand hygiene?
Social influences	Those interpersonal processes that can cause individuals to change their thoughts, feelings, or behaviors	Do other team members influence your decision to practice hand hygiene?
Emotion	A complex reaction pattern involving experiential, behavioral, and physiological elements, by which the individual attempts to deal with a personally significant matter or event	Do your emotions or mood ever influence whether you practice hand hygiene?
Behavioral regulation	Anything aimed at managing or changing objectively observed or measured actions	What could you personally do to increase your hand hygiene practice?

Table 2. κ Calculated across Last 10 Key Informant Interviews by Theoretical Domain
Theoretical domain	κ	95% confidence interval
Relevant domains
Knowledge	0.7918	0.7282–0.8554
Skills	0.8092	0.6905–0.9280
Beliefs about capabilities	0.8902	0.8019–0.9783
Beliefs about consequences	0.8233	0.7274–0.9192
Goals	0.6888	0.5189–0.8587
Memory, attention, and decision processes	0.6407	0.5197–0.7616
Environmental context and resources	0.6960	0.5539–0.8381
Social professional role and identity	0.8296	0.6909–0.9684
Social influences	0.7621	0.5850–0.9391
Nonrelevant domains
Behavioral regulation	0.4752	0.1506–0.7999
Emotion	0.8184	0.6539–0.9829
Intentions	0.9818	0.9735–0.9900
Optimism	0.6639	0.3266–1.000
Reinforcement	0.7054	0.4081–1.000
Overall (all domains)	0.7555	0.7095–0.8014

Table 3. Sample Characteristics ( N = 42)
Characteristic	N (%)
Specialty and role
Medicine staff	11 (26)
Medicine resident	10 (24)
Surgery staff	11 (26)
Surgery resident	10 (24)
Sex
Male	33 (79)
Female	9 (21)
Age, years
<30	5 (12)
31–40	18 (43)
41–50	10 (24)
51–60	6 (14)
61+	3 (7)
Experience, years
0–5	13 (31)
5.1–10	4 (10)
10.1–15	6 (14)
15.1–20	4 (10)
20+	12 (28)
Missing^a	3 (7)
Time at hospital, years
0–5	20 (48)
5.1–10	9 (21)
10.1–15	5 (12)
15.1–20	1 (2)
20+	7 (17)

^aMissing for 3 key informants: 1 medicine staff and 2 surgery residents

Table 4. Belief Statements for Relevant Theoretical Domains from Key Informant Interviews ( N = 42)
Domain and specific belief	N (%)	Interview quote
Knowledge
I believe that what I consider to be good hand hygiene fits with current guidelines	33 (79)	Q: Are you confident that what you consider to be good hand hygiene is in accordance with the current guidelines? A: I do, I think so, and based upon what I do, it tends to be from how I have been instructed to wash my hands and carry on practice, so I would hope so. (Medicine resident)
I am not confident that what I believe to be good hand hygiene fits with current guidelines	2 (18)	Q: Are you confident that what you consider to be good hand hygiene is in accordance with the current guidelines? A: Umm, probably not completely. (Medicine resident)
I am aware of hand hygiene guidelines and/or have heard of the 4 moments of hand hygiene	28 (67)	Q: Are you aware of any guidelines about hand hygiene? A: Uh, I know there are, but I've never really, like, read them or looked into them. Q: So are you familiar with the term "the 4 moments of hand hygiene"? A: Yes, sounds familiar. (Surgery resident)
I am not aware of hand hygiene guidelines and/or the 4 moments of hand hygiene	14 (33)	A: I know there are [hand hygiene guidelines], but I've never really, like, read them or looked into them. (Surgery resident) A: With the 4 what? No, I don't recall them. (Medicine staff physician)
I am aware of evidence linking hand hygiene to healthcare-associated infections	27 (64)	A: Certainly, I've seen a number of studies. I wouldn't be able to quote them, but you know they have a lot of biologic possibilities, so I'd probably just look at the abstract and agree with it. (Medicine staff)
I am not aware of evidence linking hand hygiene to healthcare-associated infections	9 (21)	Q: Are you aware of any evidence that links hand hygiene to healthcare-associated infections? A: Not that I've read, but I guess it makes sense. (Surgery staff)
Skills
I consider hand hygiene a skill	26 (62)	A: You can go in and say, "Oh, yeah, I washed my hands," but did you really wash your hands, did you really scrub them to get them clean? So yeah, it is a skill. (Medicine staff)
I do not consider hand hygiene a skill	10 (24)	A: I wouldn't call it a skill, no. I mean, I think, like, a skill is something that takes a lot of time to be able to perfect. I think it's [hand hygiene] something that if you've seen it and you know you're instructed on doing it, if you just repeat it a couple of times, it just becomes a routine thing. (Medicine resident)
I have had training in hand hygiene practice	26 (62)	Q: Were you ever trained in the proper technique for hand hygiene? A: I believe so … I cannot recall specifically, but yes, I had, like, I think it was videos showing how to do, like, you know when it's with alcohol, and then I had a specific one for doing the [surgical] scrubbing, I think. (Surgery resident)
I have not had training in hand hygiene practice	15 (36)	A: I don't think I was ever trained, no. (Surgery staff)
Beliefs about capabilities
Hand hygiene is easy to practice	36 (86)	A: It couldn't be any easier. The stuff [alcohol gel] is all over the place. (Medicine staff)
Hand hygiene is difficult to practice	8 (19)	Q: Are there any competing tasks or time constraints that might influence whether or not you practice hand hygiene? A: Well, I think, like, we were kind of saying, if you were in a situation where you're trying to do too much and you're carrying things in and out of rooms and what have you, it's not that you wouldn't be trying to practice hand hygiene but that you might not be able to do it as effectively, right. (Medicine resident)
I am confident that I am following hand hygiene guidelines when practicing hand hygiene	20 (48)	Q: Are you confident that you are following the guidelines when practicing hand hygiene? A: Again, to the extent that I know them, I believe I am, yes. (Surgery staff)
I am not confident that I am following hand hygiene guidelines when practicing hand hygiene	6 (14)	Q: Are you confident that you are following the guidelines when practicing hand hygiene? A: I don't think so, not strictly, not all of them anyway. (Surgery staff)
When there is an emergency situation, I am less likely to practice hand hygiene	14 (33)	A: Life-threatening situations. I mean, I don't see myself, you know, looking for a sink when a patient is having a cardiac arrest. (Medicine staff)
Beliefs about consequences
Practicing hand hygiene reduces the transmission of infection	41 (98)	A: The benefits [of hand hygiene] would be, like, decreased intrahospital spread of infection would be, I think, 1 important measure. (Medicine resident)
Practicing hand hygiene damages my hands	22 (52)	A: I mean, it [practicing hand hygiene] doesn't affect me with a 1-time use or a 2-time use, but if it's a consistent over time use, my hands begin to get dry and cracked, and then I get real issues if I use soaps. (Surgery staff)
It is very likely that improper hand hygiene will lead to a healthcare-associated infection	14 (33)	Q: In your opinion, how likely is it that improper hand hygiene will lead to a healthcare-associated infection? A: I think it could be very likely, depending especially on the patient you're treating and the next patient you're going to after that. (Medicine staff)
It is likely that improper hand hygiene will lead to a healthcare-associated infection	10 (24)	Q: In your opinion, how likely is it that improper hand hygiene will lead to a healthcare-associated infection? A: Not, I can't give you numbers. I wouldn't know, but I think it's pretty likely. (Surgery resident)
It is somewhat likely that improper hand hygiene will lead to a healthcare-associated infection	11 (26)	Q: In your opinion, how likely is it that improper hand hygiene will lead to a healthcare-associated infection? A: How likely? I guess somewhat likely. (Medicine staff)
It is unlikely that improper hand hygiene will lead to a healthcare-associated infection	3 (7)	A: I think it's rare, but probably the risk is not zero, but it's very small. (Surgery staff)
There are no negative aspects to practicing hand hygiene	11 (26)	A: There is no negative aspect. (Surgery staff)
Goals
Hand hygiene is always a necessity	14 (33)	Q: In what situations do you think hand hygiene is unnecessary? A: I'm not sure if any situation. I think hand hygiene is always necessary. (Surgery resident)
When taking all priorities into consideration, hand hygiene is a 10	12 (29)	Q: Considering your other priorities on a scale of 1–10, with 10 being very important, how important do you think it is for you to practice hand hygiene? A: 10, yeah, 10, it's critical. (Medicine staff)
When taking all priorities into consideration, hand hygiene is a 8–9	23 (55)	A: I would say sort of 8 out of 10, but that doesn't mean that it ranks more importantly than other things or less importantly. It's just it's an important thing to do. (Surgery resident)
When taking all priorities into consideration, hand hygiene is a 7 or less	4 (10)	Q: Considering your other priorities on a scale of 1–10, with 10 being very important, how important do you think it is for you to practice hand hygiene? A: 7. (Surgery staff)
Memory, attention, and decision processes
Hand hygiene is an automatic process for me	30 (71)	A: No, it's not a conscious decision, no, it's unconscious for sure. I don't think about it, I do it automatically. (Surgery staff)
Easily visible hand hygiene stations makes it easier to remember to practice hand hygiene	29 (69)	A: I would say that for people that are learning to get into the rhythm, it would be putting those receptacles in visible places so that they're kind of reminders when coming in and out of rooms. (Medicine resident)
Practicing hand hygiene is a conscious decision/is not an automatic process for me	25 (60)	A: Often I'm thinking, like, where is the dispenser, like, yes, I do make it a conscious decision. (Medicine staff physician)
Not practicing hand hygiene is not a conscious decision	9 (21)	A: No, I don't think there's much of a specific "I'm not going to practice hand hygiene," but sometimes you know you may forget. (Medicine resident)
Reminders are useful for my hand hygiene practice	19 (45)	A: I need reminders … as a human, I tend to forget from time to time, and if I have reminder in the hospital, I do it. (Surgery resident)
I do not need help remembering to practice hand hygiene	6 (14)	Q: Is there anything that would make it easier to remember hand hygiene? A: Umm, for me, I don't think it's an issue. (Medicine staff)
When not touching a patient or patient environment, hand hygiene is not always necessary	15 (36)	Q: In what situations do you think hand hygiene is unnecessary? A: I sometimes think it's unnecessary if I walk into a room just to have a quick chat with somebody, and I don't touch anybody or anything in the room. I don't think you need to maybe be as diligent in your handwashing just to have a conversation with somebody. (Medicine resident)
Practicing hand hygiene is a habit	8 (19)	A: It's a habit, and it's just part of cleanliness that goes along with everything. (Surgery staff)
There are no triggers that remind me to practice hand hygiene	7 (17)	A: I just try to do it [hand hygiene] before I go into the room, so it's kind of becomes a habit and when I leave, but the trigger, I'm not sure if I have any memory tricks. (Medicine resident)
There are no specific situations where I find myself forgetting to practice hand hygiene more often than others	7 (17)	Q: Are there certain situations where you find yourself forgetting to practice hand hygiene more often than others? A: Umm, that's a good question. I'd like to say I don't think so. You know, if I'm in, it doesn't matter if I'm in recovery room, ICU, our in-patient ward, or out-patient clinic. I mean, I think I make a pretty conscientious effort to do it in all those different locations. (Surgery staff)
There are specific situations where I forget to practice hand hygiene more often than others	18 (43)	A: I think I remember most times, but, you know, the thing is, so, for example, a patient in ICU with a, you know, someone's crashing in the unit. They're crashing in their bed, like I have done this several times, I admit, where I just walk in the room because you're just going after the patient, and then the nurses come back and say, "Well, the patient's MRSA," or "The patient's got C. diff," you know, like, help, just give me a gown or something and go on, but you still, you do clearly, you still forget. (Medicine staff)
Environmental context and resources
Easy access to hand hygiene stations makes it easier to practice hand hygiene (many subgroups if needed)	41 (98)	A: The negative aspect has to do with the time involved and especially the lack of convenience, and not just convenience, in fact, the decreased efficiency when rooms and hallways and patient encounters are not properly set up for appropriate hand hygiene. (Surgery resident)
Practicing hand hygiene takes time/time as a resource influences my hand hygiene practice	25 (60)	A: When you know you are very busy and you're pushing through a list of patients, it occupies your mind how to see your patients in a reasonable amount of time, so that's what displaces the thought of cleansing your hands before and after each visit. (Medicine resident)
Hand hygiene is not time consuming/no time constraints influence my hand hygiene practice	12 (29)	A: It's not time consuming for me because it's just so, you know, you do it as you're walking down the hall. You do it as you're walking into the room. You don't shake hands because your hands, like, you know, you do it in front of the patient. Like, you know, as long as you're multitasking while you're doing it, it's not time consuming. (Medicine staff)
When I am busy, I am less likely to comply with hand hygiene guidelines	20 (48)	A: As well when, you know, you are very busy and you're pushing through a list of patients, you know that's the—it occupies your mind, is, you know, how to see your patients in a reasonable amount of time, so that's what displaces, you know, the thought of cleansing your hands before and after each visit. (Medicine resident)
I do not have any feelings about current hand hygiene guidelines	16 (38)	Q: Do you have any strong feelings about the current hand hygiene guidelines? A: No, I think that I'm in agreement with them, but nothing, no strong feelings. (Medicine resident)
The location of hand hygiene stations is important in facilitating hand hygiene practice	13 (31)	A: The negative aspect has to do with the time involved and especially the lack of convenience, and not just convenience, in fact, the decreased efficiency when rooms and hallways and patient encounters are not properly set up for appropriate hand hygiene. (Surgery resident)
Social professional role and identity
Hand hygiene is a standard part of my patient consultations	40 (95)	A: In fact, I like to make it [hand hygiene] a very visible part of my patient consultation. When they first see me, I try and make sure that I'm actually still in the process of putting alcohol-based hand rub on my hands so that they know I'm performing hand hygiene. (Medicine staff)
My hand hygiene practice is in line with my peers	19 (45)	A: Everybody always thinks they're better than everybody else. No, I'm probably just average, you know. (Medicine staff)
Hand hygiene is not specific to just my specialty	14 (33)	Q: Do you think that hand hygiene is something specific to physicians in general medicine? A: I hope not. So, no. (Medicine staff)
Hand hygiene should be performed by all healthcare professionals	16 (38)	A: I think every healthcare professional has to use it [hand hygiene]. (Medicine resident)
Hand hygiene should be performed by everyone	12 (29)	A: It's something that's, uh, everybody should do. (Medicine resident)
My hand hygiene practice is better than my peers	13 (31)	A: I mean, there's going to be some physicians who do a better job of it than I do, but I would say I probably do focus on it more than the majority of them do. (Surgery staff)
Physician hand hygiene compliance is suboptimal	11 (26)	Q: What is your impression of the compliance of others in your profession with hand hygiene guidelines? A: I think it's lacking. (Surgery staff)
Social influence
Other team members influence my hand hygiene practice	15 (36)	A: I'd say when we're rounding and when you see the staff doing it, every single person that's rounding with the staff does the same thing. (Medicine resident)
Other team members do not influence my hand hygiene practice	18 (43)	Q: Do other team members influence your decision to practice hand hygiene? A: No. (Medicine staff)
Patients expectations do not influence me to perform hand hygiene	11 (26)	A: I think they [patients and their families] have a reason to expect it [hand hygiene] from us, like I don't do it to satisfy them, their wishes. (Medicine resident)
Patients expectations influence my hand hygiene practice	15 (36)	A: Yes, indirectly of course, I think the expectation from me to provide them [patients and their families] the best care, and part of that is good hand hygiene. (Surgery resident)
I have never been asked by a patient if I have performed proper hand hygiene	12 (29)	A: No, I can't remember 1 instance of feedback from any patient or their families about it [hand hygiene]. (Surgery staff)