Healthcare professionals' hand hygiene : predicting and improving practice

Abstract

This programme of research consists of eight studies which sought to determine how healthcare professionals' hand hygiene practice might be improved. The Theory of Planned Behaviour was used to isolate perceived cognitive and physical factors that may explain the variance in their hand hygiene behaviour. Practice was observed and healthcare professionals' understanding of the hand hygiene policy to which they were expected to adhere was assessed. Messages on hand hygiene posters were analysed. The effect of two educational interventions on students' attitudes was tested. Achieving change will be challenging for several reasons. Healthcare professionals hold false perceptions about their hand hygiene behaviour; they think it is better than it is but their practice is unrelated to their intentions and self-reports of behaviour. Adherence to the national guideline was poor and practice was neither rational nor informed by risk assessment, even when caring for patients colonised with methicillin-resistant Staphylococcus aureus. Student nurses' attitudes towards the importance of hand hygiene showed progressively downward trends between three cohorts in their first, second and third years of training. The difference was particularly pronounced between first and second years. Their attitudes also showed optimistic bias and false consensus beliefs. For all but one of the 11 clinical procedures measured, they said that they value hand hygiene practice significantly more than other nurses and doctors they work alongside. A microbiology laboratory practical and a demonstration using a fluorescent cream and an ultraviolet light hand inspection cabinet were equally effective at enhancing students' attitudes towards hand hygiene, but the improvement was quickly eroded by their first experience of clinical practice. Various factors in the clinical setting impact negatively on healthcare professionals' attitudes and practice and undermine the principles taught in the pre-clinical phase of training. These include poor role models, ambiguous hand hygiene policies and inappropriately framed messages on hand hygiene posters which lead to confusion in the minds of healthcare professionals about when hands should be washed. In order to improve healthcare professionals' hand hygiene behaviour, it is necessary to disambiguate their understanding about when hands should be washed. There needs to be more emphasis on infection prevention. An active process called the Dynamic Assessment Strategy for Hand Hygiene (DASHH) offers one way of changing poor practice. It does this by teaching healthcare professionals to consider hand hygiene before and after care as separate activities requiring separate risk assessment. Such a strategy provides them with a simple mind map to make the quick informed decisions that are required on a busy ward. The effectiveness of the strategy needs to be evaluated. Observation should form part of the assessment to ensure that there is a beneficial outcome and that good practice is becoming a habit.