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Improving adherence to hand hygiene practice

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Approaches to educate health professionals on hand hygiene practice must take into account “human factors” to ensure long-term adherence


Hand hygiene compliance rates continue to vary between healthcare settings and individual professionals. This article looks at how a multimodal approach to infection prevention and control, using expertise from other disciplines, can increase compliance with hand hygiene practices.

Citation: Storr J, Kilpatrick C (2013) Improving adherence to hand hygiene practice. Nursing Times; 109: 38: 12-13.

Authors: Julie Storr is president and Claire Kilpatrick is communications team leader, Infection Prevention Society; both are independent patient safety and infection prevention consultants.


Infection prevention and control teams work with staff in complex socio-technical systems to help them play their part in preventing infections. This aspect of the role can be particularly challenging. Vincent (2010) describes patient safety as “a tough problem” in cultural, technical, clinical and psychological terms.

Infection prevention and control - particularly hand hygiene compliance - is a key component to maintaining patient safety; however, bridging the gap between evidence and practice, and engaging health professionals and senior management in evidence-based infection-control practices remains an ongoing challenge.

Recent evidence has shown the effectiveness of clinical interventions in controlling the spread of infection - for example the work of Berenholtz et al (2004) in reducing catheter-related bloodstream infections in intensive care units. The impact of such interventions can be enhanced if we look beyond conventional approaches to other disciplines, such as psychology, neurosciences and ergonomics. Integrating other disciplines in approaches to hand hygiene, particularly the social sciences, has been successful to date but hand hygiene compliance is still not being sustained at an acceptable level.

This multifactorial approach to improving hand hygiene is grounded in behavioural science. It has been pioneered by the World Health Organization (2009), from whose website a toolkit of implementation resources is available.

Why is hand hygiene missed?

Hand hygiene is relatively simple to perform. However, embedding it as a habitual behaviour in healthcare, which is performed at the right times as an automatic activity, is far more complex for a number of reasons (Kilpatrick et al, 2013; WHO, 2006).

Anderson et al (2010) give five common reasons for hand hygiene behaviours not being adequately adhered to (Table 1); these provide a solid starting point to explain the complexity of hand hygiene. This research challenges the belief that infection prevention and control and hand hygiene are a matter of common sense, and encourages those working in this area to consider human factors when developing approaches to educate health professionals. These approaches are more likely to improve compliance with guidelines and recommendations.

Using a multimodal approach

Considering the factors summarised in Table 1, it is clear that a single-focused approach is unlikely to work, especially as it is well established that hand hygiene compliance rates are variable. An approach that focuses solely on education and training, without taking into account constraints that affect appropriate placement of hand-cleansing solutions, beliefs and perceptions of health professionals, and the real-life context, is unlikely to be effective. To avoid single-focused approaches, WHO has listed five inter-related parts of the WHO hand hygiene improvement strategy (Box 1).

Box 1. WHO multimodal improvement strategy 

  • Change the system
  • Train the staff
  • Monitor and audit practices
  • Promote clean hands
  • Get the culture right

Source: World Health Organization (2009) 

The WHO Hand Hygiene Self-assessment Framework (WHO, 2010) can act as a useful starting point in guiding hand hygiene improvement efforts. Based around the five parts of a multimodal strategy, it helps to measure hand hygiene improvement, allowing healthcare settings to identify where they are on the framework and to plan targeted next steps on the improvement continuum.

Allegranzi et al (2013) looked at the impact of the WHO’s improvement strategy in six pilot sites across five countries and found that it can significantly improve hand hygiene knowledge and compliance in health professionals worldwide.

A four-year research study into the multimodal “cleanyourhands” campaign, organised in England by the National Patient Safety, found it highly successful. The study highlighted a link between the availability of alcohol handrub and soap, and declining rates of MRSA and C difficile (Stone et al, 2012).

Role of nurses

Nurses play a key role in promoting many elements of hand hygiene, including:

  • Motivating other staff to perform hand hygiene during clinical activities as recommended in Five Moments for Hand Hygiene (WHO, 2006);
  • Helping design and place reminders to prompt professionals to perform hand hygiene during clinical activities;
  • Providing information on the flow of patient care to advise where alcohol handrub would be best placed;
  • Being willing and committed to revisiting, relearning and gaining understanding of the need for hand hygiene at the right times to prevent infection and save lives, and cascading this information to colleagues.


It is important to draw on available resources and solutions to improve our approach to infection prevention. Reviewing where an organisation sits on the hand hygiene improvement continuum using WHO’s self-assessment framework is an essential starting point.

The implementation of a targeted multimodal improvement strategy has been shown to reduce unnecessary patient harm and increase patient safety. Nurses have the knowledge and experience to play a key role in ensuring ongoing hand hygiene action and can act as vital links between other disciplines.

Key points

  • Engaging health professionals in infection prevention practices is one of the biggest challenges for infection prevention and control teams
  • Infection preventionand control is key to maintaining patient safety
  • Using other disciplines to support a multimodal approach can help change long-term behaviour
  • Hand cleansing is sometimes considered to be inconvenient
  • Nurses are well placed to promote hand hygiene in practice and to advise on where improvements can be made
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