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Marketing methods to improve hand hygiene compliance

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Employers have a duty to provide a safe working environment (Health and Safety at Work Act 1974). To comply with NH…


VOL: 103, ISSUE: 20, PAGE NO: 28

Linda Bissett, BN, SPQ, Dip Food Hygiene, RN, is infection control nurse, NHS Tayside primary care division, Murray Royal Hospital, Perth

Employers have a duty to provide a safe working environment (Health and Safety at Work Act 1974). To comply with NHS Scotland (2005) guidelines, NHS Tayside has a continuing update programme to ensure all sinks within clinical areas are fitted with mixer taps or temperature-controlled ones, with posters based on RCN (2005) guidelines showing the correct technique displayed at each handwash sink.



This initiative has been superseded by Health Protection Scotland’s ‘Wash your hands of them’ campaign launched in January 2007. As part of this campaign, all areas are provided with posters on hand hygiene. The infection control team (ICT) and NHS Tayside already have a hand hygiene policy that reflects evidence-based practice in compliance with standard 15 from the Clinical Standards Board for Scotland (2001).



The ICT introduced a hand hygiene system produced by Cutan c/o Deb that includes a foaming soap, moisture cream and alcohol gel. The system was wall-mounted in all clinical areas throughout NHS Tayside primary care sites. In areas where wall-mounted alcohol gels may prove a high risk, for example forensic psychiatry, individual alcohol dispensers were provided. Following a risk assessment, alcohol gel dispensers were placed at ward entrances where it was deemed safe to do so, to encourage staff and visitors to decontaminate their hands before entering and leaving the area.





Marketing can be described as creating beneficial products and services for customers, communicating their availability in a persuasive manner and delivering these products and services to the customer with ease of accessibility. Mah et al (2006) put forward the idea that, in return for receiving something of value, the customer (healthcare worker) provides something of benefit to the organisation (NHS) and its stakeholders (the patients). They also suggested that perceived self-interest is a greater driver of behaviour than altruism (the benefit to patients).



Following the installation of the hand hygiene system, healthcare workers were provided with education on hand hygiene and the correct use of alcohol rubs to ensure the product was applied effectively.



The marketing highlighted the benefits to staff of using alcohol rubs. While describing the effective use of the rubs, this highlighted the potential for reducing the time needed to decontaminate skin, as rubs are often more accessible than sinks. The protection that the emollient content of the rub gave to skin and the reduction of potential pathogens on workers’ hands were also emphasised.



Healthcare workers were encouraged to take ownership of their own hand hygiene with an awareness programme using hand inspection cabinets. These enabled staff to see how well their technique reduced the amount of contaminants on their skin. The marketing helped them to identify their skincare needs and promoted the use of the moisturisers to protect skin. Individuals were also able to identify areas where improvement was required to ensure their own safety.





A presentation was developed that incorporated: the history of hand hygiene; research on the subject; the importance of hand hygiene in the prevention of cross-contamination; the negative effects of non-compliance; and the individual’s responsibility to comply with guidelines.



The importance of skincare to protect skin from damage - thereby maintaining a barrier against bacterial invasion - was stressed, as was the need for compliance to the no-jewellery rule. Damaged skin has a higher bacterial count than intact skin, so good skincare was encouraged to reduce the risk of cross-infection, especially among those who are susceptible, for example those with diabetes or staff with skin problems.



The accountability of the healthcare worker was emphasised to ensure that staff were fully aware that compliance with guidelines was each individual’s personal responsibility and that non-compliance could be viewed as failure in duty of care.





A handwashing demonstration by the infection control nurse, who then observed each person’s handwashing technique, followed the presentation. After each person’s handwash, workers were asked how efficient they considered their technique to be.



Staff were then asked to apply a cream that glows under the hand inspection light and asked to examine the effectiveness of their handwash using the cabinets to highlight areas where they needed to improve their technique.





A questionnaire was distributed three months after the hand hygiene sessions were completed to ascertain health workers’ views of the effectiveness of the marketing approach.



Snapshots of hand hygiene compliance rates and observations of hand hygiene technique followed this. To ensure the technique for scoring compliance was the same, I completed all the snapshots.





A total of 50 questionnaires were distributed, of which 48 were completed (96%). Of the 48 staff who completed the questionnaire, 84% approved of the hand hygiene system being in place in the primary care setting.



Some 92% of the respondents found the hand hygiene sessions beneficial and informative and were pleased that their needs were being addressed. Most (85%) indicated that the self-assessment of handwashing technique raised awareness of the need for improvement.



Before the education sessions, 68% of respondents had not been aware that non-compliance with hand hygiene could be construed as failure in their duty of care and were pleased that this had been highlighted. Following the education sessions, 82% thought that they had sustained their improved practice.





Snapshots of hand hygiene compliance lasting one hour were completed in three areas where education sessions had taken place. A total of 141 hand hygiene opportunities were observed. The percentage of opportunities taken ranged from 71 to 92%. The average compliance rate was 85%. Compliance with hand hygiene technique varied between 76% and 100% (average 91%). Nurses averaged 93%; HCAs 95%; nursing students 100%; medical staff 76%; support services 90%; and allied health professionals 94%.



A covert observation of hand hygiene compliance was carried out within each area for a period of 15 minutes a month after the snapshots to ensure that the high compliance rates seen for both opportunity and technique were not based on increases caused by the Hawthorn effect (in which people who are being observed act differently from normal).



Staff felt that the increase in their knowledge of cross-contamination via workers’ hands made them more confident about challenging bad practice. They also indicated that they were more aware of the personal benefits of complying with guidelines and believed that compliance improved due to their increased knowledge.





The positive results indicate that using marketing methods improves compliance. Considering the snapshots and the covert observations took place 3-4 months after the sessions, the positive effect appears to be sustained for longer than in previous research. Study of a larger group is required to ensure the results show a true picture.





- The compliance rates achieved indicate that education sessions based on social marketing techniques have had a positive effect on hand hygiene practice.



- The marketing of hand hygiene guidelines has enabled staff to identify the benefits to themselves as well as to patients.



- Healthcare workers said they were more aware of the need to comply with guidelines to ensure both their own and patient safety, because reflection on the negative effects of non-compliance was encouraged.



- The emphasis on the benefits to staff of adherence appears to have made healthcare workers more likely to examine their own practice.



- Healthcare workers are more aware that long-term improvement is dependent on each individual taking care in practice.





- Research indicates that compliance with hand hygiene guidelines rarely exceeds 40% (Cohen et al, 2002).



- Social marketing was used successfully by the National Patient Safety Agency (2004) to launch its cleanyourhands campaign. Health Protection Scotland (2007) also used this method.



- Using hand inspection cabinets gives individuals insight into the efficiency of their own hand decontamination technique and highlights areas for improvement (Bissett and Craig, 2005).



This article has been double-blind peer-reviewed.

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