Hand hygiene compliance in intensive care units: An observational study

Assessing the incorporation of the 'Five Moments for Hand Hygiene' into nursing procedure textbooks

AIM

Our aim was to conduct a thorough comparison between the hand hygiene information included in international nursing textbooks and the Slovenian nursing textbook's equivalent content as it relates to nursing procedures.

BACKGROUND

Hand hygiene practices are crucial in preventing healthcare-associated infections, which affect millions of patients annually. The idea behind "Five Moments for Hand Hygiene" is to encourage assessing success and boosting self-efficacy.

DESIGN

Comparison of hand hygiene content in international nursing textbooks with the content in a Slovenian nursing textbook.

METHODS

A study was conducted between March 2023 and March 2024 to compare hand hygiene content in international nursing textbooks. The study included textbooks from the USA and UK, as well as Slovenian (SI) textbooks. The final phase involved comparing hand hygiene performance practices against the WHO Five Moments for Hand Hygiene.

RESULTS

The study reviewed 470 nursing procedures across three textbooks, identifying four common ones: female indwelling urinary catheterisation, small-bore feeding tube insertion, enema administration and subcutaneous injections. The USA textbook had the highest number of steps, while the UK textbook had the lowest. Clean protective gloves are not recommended for all nursing procedures, only for small-bore feeding tube insertion and enema administration. The US textbook omitted 12 steps for the female indwelling urinary catheter procedure, while the UK textbook included 10 steps. The SI textbook omitted 8 steps.

CONCLUSIONS

Hand hygiene is crucial for healthcare infections prevention and control. The study found differences in the frequency of hand hygiene in these nursing procedures. WHO's Five Moments for Hand Hygiene guidelines are not universally accepted, with inadequate hygiene often observed before patient contact. Future research should review foreign textbooks and update existing ones.

Associations between self-leadership and self-reported execution of infection prevention and control among physicians and nurses

BACKGROUND

There is poor self-reported (SR) execution of infection prevention and control (IPC) among physicians and nurses. Self-leadership is considered an important factor to enhance IPC SR-execution. This study aims to explore the associations between self-leadership and IPC SR-execution among physicians and nurses.

METHODS

A cross-sectional study of 26,252 physicians and nurses was conducted in all secondary and tertiary hospitals in Hubei province, China. A questionnaire was designed to measure physicians' and nurses' self-leadership, which includes positive traits and negative traits, and IPC SR-execution, which includes motivation, process, and outcome.

RESULTS

Positive traits and negative traits of self-leadership had significant positive associations with SR-execution motivation (β = .582, P < .001) (β = .026, P < .001), SR-execution process (β = .642, P < .001) (β = .017, P < .001), and SR-execution outcome (β = .675, P < .001) (β = .013, P < .001).

CONCLUSIONS

This study recommends that health care institutions should focus on cultivating positive traits of self-leadership among physicians and nurses. Although negative traits of self-leadership can also promote IPC SR-execution, the association is limited and may lead to risks.

Have Hand Hygiene Practices in Two Tertiary Care Hospitals, Freetown, Sierra Leone, Improved in 2023 following Operational Research in 2021?

In 2021, an operational research study in two tertiary hospitals in Freetown showed poor hand hygiene compliance. Recommended actions were taken to improve the situation. Between February-April 2023, a cross-sectional study was conducted in the same two hospitals using the World Health Organization hand hygiene tool to assess and compare hand hygiene compliance with that observed between June-August 2021. In Connaught hospital, overall hand hygiene compliance improved from 51% to 60% (p < 0.001), and this applied to both handwash actions with soap and water and alcohol-based hand rub. Significant improvements were found in all hospital departments and amongst all healthcare worker cadres. In 34 Military Hospital (34MH), overall hand hygiene compliance decreased from 40% to 32% (p < 0.001), with significant decreases observed in all departments and amongst nurses and nursing students. The improvements in Connaught Hospital were probably because of more hand hygiene reminders, better handwash infrastructure and more frequent supervision assessments, compared with 34MH where interventions were less well applied, possibly due to the extensive hospital reconstruction at the time. In conclusion, recommendations from operational research in 2021 contributed towards the improved distribution of hand hygiene reminders, better handwash infrastructure and frequent supervision assessments, which possibly led to improved hand hygiene compliance in one of the two hospitals. These actions need to be strengthened, scaled-up and guided by ongoing operational research to promote good hand hygiene practices elsewhere in the country.

Action research on promoting hand hygiene practices in an intensive care unit

AIM

Evaluate the intensive care acquired infections incidence and the change over time in infection practices in one intensive care unit.

DESIGN

We used an action research approach with cyclical activities.

METHODS

Our study included two cycles with hand hygiene observation based on the WHO's five-moments observation tool, observing hand hygiene practices, analysing the observations, and giving feedback on observations, intensive care acquired infection rates, and alcohol-based hand rub consumption. The Revised Standards for Quality Improvement Reporting Excellence is the basis for this research report describing research aimed at improving patient safety and quality of care.

RESULTS

During the study, annual alcohol-based hand rub consumption increased by 6.7 litres per 1000 patient days and observed hand hygiene compliance improved. In the first cycle of the study, there was a decrease in critical care acquired infection rates, but the improvement was not sustainable.

Eye-tracking to observe compliance with hand hygiene in the intensive care unit: a randomized feasibility study

BACKGROUND

Healthcare-associated infections are associated with increased patient mortality. Hand hygiene is the most effective method to reduce these infections. Despite simplification of this easy intervention, compliance with hand disinfection remains low. Current assessment of hand hygiene is mainly based on observation by hygiene specialists. The aim of this study was to investigate additional benefits of eye-tracking during the analysis of hand hygiene compliance of healthcare professionals in the intensive care unit.

METHODS

In a simulated, randomized crossover study conducted at the interdisciplinary intensive care unit at University Hospital Zurich, Switzerland, doctors and nurses underwent eye-tracking and completed two everyday tasks (injection of 10 μg norepinephrine via a central venous line, blood removal from the central line) in two scenarios where the locations of alcoholic dispensers differed ('in-sight' and 'out-of-sight'). The primary outcomes were dwell time, revisits, first fixation duration and average fixation duration on three areas of interest (central venous line, alcohol dispenser, protective glove box) for both scenarios. Compliance with hand hygiene guidelines was analysed.

FINDINGS

Forty-nine participants (35 nurses, 14 doctors) were included in this study. Eye-tracking provided additional useful information compared with conventional observations. Dwell time, revisits, first fixation duration and average fixation duration did not differ between the two scenarios for all areas of interest. Overall compliance with recommended hand hygiene measures was low in both doctors (mean 20%) and nurses (mean 42.9%).

CONCLUSION

Compared with conventional observations, eye-tracking offered additional helpful insights and provided an in-depth analysis of gaze patterns during the recording of hand hygiene compliance in the intensive care unit.

Reducing Carbapenem-Resistant Enterobacteriaceae Using the Targeted Solution Tool: A Quality Improvement Project

BACKGROUND

Carbapenem-resistant Enterobacteriaceae (CRE) is a worldwide urgent health problem. Hand hygiene (HH) is an effective intervention to reduce the spread of CRE.

LOCAL PROBLEM

In 2017, an increase in the rate of health care-associated (HA) CRE colonization was observed in a large multiorgan transplant center in Italy. This study aimed to reduce the HA-CRE colonization rates by improving HH compliance.

METHODS

A pre-/post-intervention project was conducted from November 2017 through December 2020.

INTERVENTIONS

The DMAIC (Define, Measure, Analyze, Improve, and Control) framework was used to implement the HH Targeted Solution Tool (TST).

RESULTS

Hand hygiene compliance increased from 49% to 76.9% after the Improve phase ( P = .0001), and to 81.9% after the second Control phase ( P = .0001). The rate of HA-CRE decreased from 24.9% to 5.6% ( P = .0001).

CONCLUSIONS

Using the DMAIC framework to implement the TST can result in significant improvements in HH compliance and HA-CRE colonization rates.

The impacts of self-expectation leadership and organizational commitment on hand hygiene behavior of medical staff based on the theory of implicit leadership

Hand hygiene behavior (HHB) in healthcare settings remains suboptimal globally. Self-expectation leadership and organizational commitment are emphasized as important factors influencing HHB. However, there are no studies to support any relationship between self-expectation leadership and organizational commitment to HHB. This study will fill the gap by applying implicit leadership theory (ILT) to support the further promote HHB among medical staff. A cross-sectional study of 23,426 medical staff was conducted in all second-level and third-level hospitals in Hubei province, China. Based on ILT, an online self-administered and anonymous questionnaire was designed for measuring the medical staff’s self-expectation leadership, organizational commitment, and HHB based on Offermann’s 8 dimensions scale, Chang’s 3 dimensions scale, and the specification of hand hygiene for healthcare workers, respectively, in which self-expectation leadership was divided into positive traits and negative traits parts. The structural equation model was used to examine the direct, indirect, and mediating effects of the variables. Positive traits of self-expectation leadership had a positive effect on organizational commitment (β = 0.617, p &lt; 0.001) and HHB (β = 0.180, p &lt; 0.001). Negative traits of self-expectation leadership had a negative effect on organizational commitment (β = –0.032, p &lt; 0.001), while a positive effect on HHB (β = 0.048, p &lt; 0.001). The organizational commitment had a positive effect on HHB (β = 0.419, p &lt; 0.001). The mediating effect of the organizational commitment showed positively between positive traits of self-expectation leadership and HHB (β = 0.259, p &lt; 0.001), while negatively between negative traits of self-expectation leadership and HHB (β = –0.013, p &lt; 0.001). Positive traits of self-expectation leadership are important predictors of promoting organizational commitment and HHB, while negative traits of self-expectation leadership have a limited impact on organizational commitment and HHB in the field of healthcare-associated infection prevention and control. These findings suggest the need to focus on positive traits of self-expectation leadership; although negative traits of self-expectation leadership can also promote HHB to a lesser degree among medical staff, it will reduce their organizational commitment.

Hand Hygiene Compliance Rates in 9 Pediatric Intensive Care Units Across Europe: Results from the Reducing Antimicrobial use and Nosocomial Infections in Kids Network

A unified surveillance mechanism for hand hygiene and hospital-acquired infections for pediatric wards is lacking in Europe. We managed to setup such a mechanism in 9 pediatric intensive care units in 7 European countries, using World Health Organization's definitions and common methodology which allows for benchmarking among units and countries. Median hand hygiene compliance was found high 82.3% (interquartile range 71.6-94.5%), but gaps in practices were identified.

Hand hygiene compliance by direct observation in physicians and nurses: a systematic review and meta-analysis

BACKGROUND

Direct observation of hand hygiene compliance is the "gold standard" despite limitations and potential for bias. Previous literature highlights poorer hand hygiene compliance amongst physicians than nurses and suggests that covert monitoring may give better compliance estimates than overt monitoring.

AIM

This review aimed to explore differences in compliance between physicians and nurses further, and to analyse if compliance estimates differed when observations were covert rather than overt.

METHODS

A systematic search of databases PubMed, EMBASE, CENTRAL and CINAHL was performed. Experimental or observational studies in hospital settings in high-income countries published in English from 2010 onwards were included if estimates for both physicians and nurses using direct observation were reported. The search yielded 4814 studies, of which 105 were included.

FINDINGS

The weighted pooled compliance rate for nurses was 52% (95% CI 47% to 57%) and for doctors was 45% (95% CI 40% to 49%). Heterogeneity was considerable (I²=99%). The majority of studies were at moderate or high risk of bias. Random-effects meta-analysis of low risk of bias studies suggests higher compliance for nurses than physicians for both overt (difference of 7%, 95% CI for the difference 0.8% to 13.5%, p=0.027) and covert (difference of 7%, 95% CI 3% to 11%, p=0.0002) observation. Considerable heterogeneity was found in all analyses.

CONCLUSION

Wide variability in compliance estimates and differences in the methodological quality of hand hygiene studies were identified. Further research with meta-regression should explore sources of heterogeneity and improve the conduct and reporting of hand hygiene studies.

Effects of Micro Architectural Environmental Interventions on Handwashing Compliance of Adolescents: A School-Based Intervention Trial

PURPOSE

Aimed to explore more practical interventions for handwashing compliance (HWC) and protect the minor' health with the pandemic background, this study tested whether micro architectural interventions would promote HWC of adolescents through active experience.

BACKGROUND

Despite the well-documented benefits of handwashing (HW), low compliance is common among adolescents. HW space in schools has always been treated as attached spaces of little matter, which is unfavorable to public health. According to environment behavior perspective, personal motivation of HWC may be motivated by active environment.

METHOD

A school-based investigation and a 30-week environmental behavior experiment were conducted when students returned to school after the COVID-19 pandemic closure in 2020 in China to evaluate the effects of active environment interventions selected by previous survey on promoting adolescents' HW rate. Digital infrared counters were used to unobtrusively document their behavior.

RESULTS

Results in summer revealed a positive effect on all intervention groups. The effects of combined interventions were higher than the effect of any single intervention. However, HW rates of all groups declined sharply in the coldest month and the between-group differences decreased. Significant correlations were found between HW rates and satisfaction with the intervention schemes.

CONCLUSIONS

Findings suggest that architectural environmental intervention may potentially be a positive, friendly, and one-time investment mean to expand the HWC intervention scope from passive policies to positive experience, and HW space design for adolescents should be treated as a public health strategy.

Using patient-reported outcome measures in psychiatric hospital care: an observational study describing an iterative implementation process in Denmark

BACKGROUND

Patient-reported outcomes (PROs) are increasingly recognized as valuable sources of information to enhance our understanding of the quality of healthcare from the patient's perspective.

OBJECTIVE

This study aimed to describe the implementation process of the Danish nationwide PRO-Psychiatry project, including iterative tests of previously developed PRO measurement concept and an online data collection tool. Additional aims were to identify the 'best practice' for the routine use of PROs in hospital-based psychiatry and design information material about the project.

METHODS

We conducted an action-oriented observational study to explore the pilot implementation of the PRO-Psychiatry project, which was initiated in February 2018. The study was based on an iterative plan-do-learn approach. An inpatient unit and an outpatient unit from the same psychiatric department in the North Denmark Region were selected for the pilot implementation. The implementation was anchored in multidisciplinary implementation teams at unit level. These teams managed the implementation process according to four tasks defined by the department management.

RESULTS

The teams designed, tested, evaluated and adjusted the localized work practices relating to the use of PRO-Psychiatry. The comprehensibility of the predesigned PROs, the usability of the Information Technology(IT) system and the routine use of PROs during clinical consultations were repeatedly tested and adjusted until the functionality was satisfactory. Furthermore, the teams designed information material for patients (emails, posters, handouts and webpages) and clinicians (online clinical guidelines). The team members informed their colleagues about the progress of PRO-Psychiatry at staff meetings and rolled out the initiative through one-to-one teaching.

CONCLUSIONS

The pilot implementation was deemed successful. PRO-Psychiatry was rolled out to other units in the region, and a national decision was made to pilot implement the initiative in the other four Danish regions.

Hand Hygiene Compliance at Two Tertiary Hospitals in Freetown, Sierra Leone, in 2021: A Cross-Sectional Study

Hand hygiene actions are essential to reduce healthcare-associated infections and the development of antimicrobial resistance. In this cross-sectional study at two tertiary hospitals, Freetown, Sierra Leone, we observed hand hygiene compliance (defined as using handwash with soap and water or alcohol-based hand rub (ABHR) amongst healthcare workers between June and August 2021. Using the WHO Hand Hygiene tool, observations were made in relation to the type of opportunity, different wards and types of healthcare worker. Overall, 10,461 opportunities for hand hygiene were observed, of which 5086 (49%) resulted in hand hygiene actions. ABHR was used more often than handwash (26% versus 23%, p < 0.001). Overall, compliance was significantly better: after being with a patient/doing a procedure than before (78% after body fluid exposure risk compared with 24% before touching a patient—p < 0.001); in Paediatric (61%) compared with Medical wards (46%)—p < 0.001; and amongst nurses (52%) compared with doctors (44%)—p < 0.001. Similar patterns of compliance were observed within each hospital. In summary, hand hygiene compliance was sub-optimal, especially before being with a patient or before clean/aseptic procedures. Improvement is needed through locally adapted training, hand hygiene reminders in wards and outpatient departments, uninterrupted provision of ABHR and innovative ways to change behaviour.

An Intra-COVID-19 Assessment of Hand Hygiene Facility, Policy and Staff Compliance in Two Hospitals in Sierra Leone: Is There a Difference between Regional and Capital City Hospitals?

Although hand hygiene (HH) is the most effective intervention to reduce the spread of infections, there are limited data on HH facilities, policy, and compliance in sub-Saharan Africa. This cross-sectional study is aimed at assessing HH using the WHO HH self-assessment framework, HH technical reference manual, and a modified infection control self-assessment tool in two hospitals in Sierra Leone. Only 10% and 9% of regional and capital city hospitals had running tap water, respectively. Veronica buckets were the resources for HH in 89% of units in the regional hospital and 92% of units in capital city hospital. Constant supply of soap and alcohol-based hand rub was available in 82% and 68%; and 74% and 79% of units in the capital city and regional hospitals, respectively. Only 10% of the units in both hospitals had hand-drying facilities and functional sinks. Overall HH compliance for the two hospitals was 18.6% and was higher in the regional (20.8%) than the capital city (17.0%) hospitals. The HH levels for the capital city and regional hospitals were 277.5 and 262.5 respectively. Despite the COVID-19 pandemic, there are still challenges with HH compliance in Sierra Leone. It is, therefore, necessary to strengthen the HH multi-modal strategy.

[Level of Complete Knowledge on Five Moments of Hand Hygiene among Nurses Working at Integrated Nursing Care Service Wards]

PURPOSE

This study aimed to identify the level of complete knowledge about hand hygiene indications among nurses working at integrated nursing care service wards.

METHODS

A total of 127 nurses in eight integrated nursing care service wards completed structured sheets while observing a video based on six scenarios developed by the research team. Complete knowledge level was calculated as the percentage (%) of participants who responded correctly to all questions among participants. Complete knowledge levels according to the scenarios were calculated and compared according to general characteristics using the chi-squared test or Wilcoxon rank-sum test.

RESULTS

The complete knowledge level for each scenario ranged from 7.9% (scenario 6) to 42.5% (scenarios 4 and 5), and no one had complete knowledge of all scenarios. Only 3.1% of participants demonstrated complete knowledge in more than four scenarios, and 26.0% had complete knowledge of four or more hand hygiene moments. Complete knowledge level per scenario did not differ depending on work experience at hospitals and study wards, or prior hand hygiene training in the last year.

CONCLUSION

As the complete knowledge level regarding hand hygiene moment is very low, it is suggested that regular hand hygiene training should be provided to nurses using video media that reflect real nursing tasks. Thus, they can acquire complete knowledge of when hand hygiene is needed or not during complex nursing work situations.

Impact of Hand Hygiene on Hospital-Acquired Infection Rate in Neuro Trauma ICU at a Level 1 Trauma Center in the National Capital Region of India

Introduction  Compliance to hand hygiene (HH) is an important measure in preventing infections to patients in health-care settings. Wellness and safety of patients and health-care workers (HCWs) can be achieved by promoting best practices in infection control through education and advocacy.

Aims and Objectives  To assess the compliance to HH among all cadres of HCWs and its association with hospital-acquired infection (HAI) in patients.

Materials and Methods  A prospective, observational study was conducted for a period of 5 years (January 2014 to December 2018) in Neuro Trauma intensive care unit. A standard checklist based on World Health Organization’s 5 Moments for Hand Hygiene was used as a tool to measure the HH compliance.

Results  HAI rate was found to be directly proportional to the compliance to HH. Reduction in HAI rates was reported when there was an increase in HH compliance. HAI of 4.25% was found to be lowest in the year 2015 with the compliance to HH of 63.65%. The HH compliance was also found to be highest (64.63%) in the year 2016 followed by 64.12% in the year 2017. During this period HAI rates were 4.35% and 4.8%, respectively. When the HH compliance declined in the year 2018 to 53.95%, there was an increase in the rate of HAI to 6.9%.

Conclusion  It could be concluded that HH compliance was associated with the decrease in HAIs. HH could be a simple and cost-effective method in the prevention of HAIs.

Identifying interventions to improve hand hygiene compliance in the intensive care unit through co-design with stakeholders

Background: Despite the effectiveness of hand hygiene (HH) for infection control, there is a lack of robust scientific data to guide how HH can be improved in intensive care units (ICUs).  The aim of this study is to use the literature, researcher, and stakeholder opinion to explicate potential interventions for improving HH compliance in the ICU, and provide an indication of the suitability of these interventions. Methods: A four-phase co-design study was designed. First, data from a previously completed systematic literature review was used in order to identify unique components of existing interventions to improve HH in ICUs. Second, a workshop was held with a panel of 10 experts to identify additional intervention components. Third, the 91 intervention components resulting from the literature review and workshop were synthesised into a final list of 21 hand hygiene interventions. Finally, the affordability, practicability, effectiveness, acceptability, side-effects/safety, and equity of each intervention was rated by 39 stakeholders (health services researchers, ICU staff, and the public). Results: Ensuring the availability of essential supplies for HH compliance was the intervention that received most approval from stakeholders. Interventions involving role models and peer-to-peer accountability and support were also well regarded by stakeholders. Education/training interventions were commonplace and popular. Punitive interventions were poorly regarded. Conclusions: Hospitals and regulators must make decisions regarding how to improve HH compliance in the absence of scientific consensus on effective methods. Using collective input and a co-design approach, the guidance developed herein may usefully support implementation of HH interventions that are considered to be effective and acceptable by stakeholders.

Identifying interventions to improve hand hygiene compliance in the intensive care unit through co-design with stakeholders

Background: Despite the effectiveness of hand hygiene (HH) for infection control, there is a lack of robust scientific data to guide how HH can be improved in intensive care units (ICUs).  The aim of this study is to use the literature, researcher, and stakeholder opinion to explicate potential interventions for improving HH compliance in the ICU, and provide an indication of the suitability of these interventions. Methods: A four-phase co-design study was designed. First, data from a previously completed systematic literature review was used in order to identify unique components of existing interventions to improve HH in ICUs. Second, a workshop was held with a panel of 10 experts to identify additional intervention components. Third, the 91 intervention components resulting from the literature review and workshop were synthesised into a final list of 21 hand hygiene interventions. Finally, the affordability, practicability, effectiveness, acceptability, side-effects/safety, and equity of each intervention was rated by 39 stakeholders (health services researchers, ICU staff, and the public). Results: Ensuring the availability of essential supplies for HH compliance was the intervention that received most approval from stakeholders. Interventions involving role models and peer-to-peer accountability and support were also well regarded by stakeholders. Education/training interventions were commonplace and popular. Punitive interventions were poorly regarded. Conclusions: Hospitals and regulators must make decisions regarding how to improve HH compliance in the absence of scientific consensus on effective methods. Using collective input and a co-design approach, the guidance developed herein may usefully support implementation of HH interventions that are considered to be effective and acceptable by stakeholders.

Impact of multimodal strategies to reduce multidrug-resistant organisms in surgical intensive care units: Knowledge, practices and transmission: A quasi-experimental study

Aim

This study examined the effects of multimodal strategies on knowledge and practices in preventing multidrug‐resistant organism (MDRO) transmission among healthcare personnel (HCP), and to investigate MDRO transmission in two surgical intensive care units (SICUs).

Design

A quasi‐experimental study with a one‐group pretest–posttest design.

Methods

We recruited 62 HCP. Data were collected during 2017–2019. Multimodal strategies, including training, educational and reminder posters, an educational YouTube channel, champions and feedback, were used to enhance knowledge and practices. Data were analysed using Wilcoxon signed‐rank test and chi‐square test.

Results

After the intervention, median knowledge scores increased from 16.0 to 17.0 (p = .001), and overall correct MDRO prevention practices increased from 76.6% to 94.0% (p < .001). The MDRO transmission rate decreased from 25% to 0% (p < .001).

Conclusion

The findings indicate that multimodal strategies could enhance knowledge and practices for preventing MDRO transmission among HCP and could reduce the MDRO transmission rate in SICUs.

Understanding hand hygiene behaviour in the intensive care unit to inform interventions: an interview study

BACKGROUND

Improving hand hygiene (HH) compliance is one of the most important, but elusive, goals of infection control. The purpose of this study was to use the capability (C), opportunity (O), motivation (M), and behaviour (B; COM-B) model and the theoretical domains framework (TDF) to gain an understanding of the barriers and enablers of HH behaviours in an intensive care unit (ICU) in order to identify specific interventions to improve HH compliance.

METHODS

A semi-structured interview schedule was developed based upon the COM-B model. This schedule was used to interview a total of 26 ICU staff: 12 ICU nurses, 11 anaesthetic specialist registrars, and three anaesthetic senior house officers.

RESULTS

Participants were confident in their capabilities to carry out appropriate HH behaviours. The vast majority of participants reported having the necessary knowledge and skills, and believed they were capable of carrying out appropriate HH behaviours. Social influence was regarded as being important in encouraging HH compliance by the interviewees- particularly by nurses. The participants were motivated to carry out HH behaviours, and it was recognised that HH was an important part of their job and is important in preventing infection. It is recommended that staff are provided with targeted HH training, in which individuals receive direct and individualised feedback on actual performance and are provided guidance on how to address deficiencies in HH compliance at the bedside at the time at which the HH behaviour is performed. Modelling of appropriate HH behaviours by senior leaders is also suggested, particularly by senior doctors. Finally, appropriate levels of staffing are a factor that must be considered if HH compliance is to be improved.

CONCLUSIONS

This study has demonstrated that short interviews with ICU staff, founded on appropriate behavioural change frameworks, can provide an understanding of HH behaviour. This understanding can then be applied to design interventions appropriately tailored to the needs of a specific unit, which will have an increased likelihood of improving HH compliance.