An investigation into the factors that predict nurses’ handwashing behaviour and interventions that might increase hand hygiene
Declan Hanna, DClinPsych, BSc, is clinical psychologist, department of clinical psychology, Belfast City Hospital; Martin Dempster, PhD, BSc, is lecturer in health psychology, school of psychology, Queen’s University Belfast; Mark Davies, DClinPsych, BSc, is consultant clinical psychologist, department of clinical psychology, Belfast City Hospital.
Hanna, D. et al (2009) The role played by a range of psychological variables in nurses’ handwashing behaviour. Nursing Times; 105: 41, early online publication.
Background: Psychological models of behaviour change are used to predict patients’ health behaviours but have rarely been used to explore healthcare professionals’ health-related behaviour.
Aim: To explore the association between self-reported handwashing and a range of psychological variables in a sample of nurses in a large acute hospital.
Results and discussion: Nurses in this study were more likely to wash their hands if they perceived it to be important and if they thought their workplace helped them in doing so. The best predictor of perceived importance was how strongly a nurse believed that poor handwashing practice contributes to spreading infection.
Conclusion: In this study, psychological variables such as perception of importance, perception of workplace support, occupational stress and perception of risk were important predictors of handwashing behaviour.
Keywords: Handwashing, Psychological variables, Infection control, Hand hygiene
- This article has been double-blind peer reviewed
- Interventions aimed at increasing nurses’ perception of the importance of handwashing and measures that influence their perceptions regarding the supportiveness of their employer (such as initiatives to reduce occupational stress) may contribute to longer-term changes in handwashing.
- The issue of how poor handwashing practice contributes to the spread of infection should be emphasised in all interventions to increase this health behaviour.
- More research should examine the role of other psychological processes in infection control.
Good hand hygiene is an integral aspect of infection control, though handwashing rates among healthcare professionals remain low (Huggonet et al, 2002; Pittet et al, 1999). Studies have reported rates of handwashing from 63% (Randle et al, 2006) to 9% (Feather et al, 2000).
Attempts to improve handwashing include interventions such as: education (Pittet et al, 2000); providing decontaminant materials (Teare et al, 2001); and giving feedback on handwashing performance (Larson et al, 1997). These interventions often modify the working environment or emphasise the risks of not adhering to handwashing guidelines, though research suggests the improvements in hand hygiene as a result of the interventions are often transitory (Naikoba and Hayward, 2001).
Unlike attempts to influence professionals’ behaviour, strategies aimed at changing patient behaviours are established and evidence-based. A number of psychological constructs such as self-efficacy (alongside risk perception and environmental changes) help to account for how patients can be encouraged to change behaviour in response to medical needs, for example managing glycaemic control in diabetes (Peyrot et al, 1999).
Severaltheories combine these constructs in different ways to predict “health behaviours”, such as the health belief model (Rosenstock, 1974), the theory of planned behaviour (Ajzen, 1991) and stage models including the trans-theoretical model (Prochaska and DiClemente, 1983).
Given the evidence that these constructs help predict patients’ long term adoption of health behaviours, it is surprising that few studies have examined the relationship between these variables and healthcare professionals’ health-related behaviours.
This study examined the relationship between a range of psychological constructs - including self-efficacy, perceived risk and psychological distress (occupational stress) - and nurses’ self-reported handwashing behaviour. The influence of other variables, including demographics, training received and the perceived support provided by the organisation towards handwashing were also explored.
A cross sectional correlation design was used. Participants were sampled from a large acute hospital with cardiology, dermatology, general medicine, haematology, nephrology, oncology, respiratory, surgery and urology wards.
The research team attended ward rounds/team meetings to give an overview of the study and distribute questionnaire packs. These contained written information on the study and reassured potential participants of anonymity. Nurses who decided to participate were asked to read and sign a consent form and to return the completed battery of questionnaires (at their convenience) in an SAE.
Questionnaires asked for demographic information on participants’ gender, age, ethnic background, medical specialism, length of time worked in the NHS and whether their post required hands on contact with patients.
Participants were also given a statement on handwashing recommendations and were asked to rate the frequency they thought they achieved this over a three-month period using a 10cm visual analogue scale (VAS) - 0 represented “never” and 10 represented “always follow recommendation”. Such scales have been shown to be reliable and valid measures of subjective experience (Folstein and Luria, 1973).
Similar scales were used to determine:
- The importance nurses placed on adhering to handwashing recommendations;
- The assistance nurses perceived their employer gave them in relation to handwashing;
- Their perceptions of risk to self and others associated with not performing handwashing in accordance with guidelines;
- The degree to which they believed that handwashing contributes to reducing infection transmission.
Respondents were also asked if they had received any formal training in handwashing techniques and, if so, the nature of this training.
Two standard questionnaires were also used:
- Nursing Stress Scale (NSS; Gray-Toft and Anderson, 1981) - a 34-item scale designed to measure occupational stress in nurses;
- Generalised Self-Efficacy Scale (GSES; Schwarzer and Jerusalem, 1995) -a 10-item self-report scale that assesses an individual’s belief in their ability to respond to “novel or difficult situations” and to overcome obstacles.
Ethical approval was obtained from the trust research governance committee and the NHS Office for Research Ethics Committees.
Some 237 questionnaires were distributed, of which 76 were returned (response rate of 32%). Participants’ average age was 34.3 years. More women responded than men (73 women versus three men). Most participants (92%) were classified as European (4% were classified as Asian and three respondents did not specify their ethnicity). Average length of time spent working in the NHS was 12.9 years (range 0.5-37). The entire sample indicated their roles required “hands on” patient contact.
One-way analysis of variance (ANOVA) investigated the effects of demographic variables on self-reported handwashing: gender (p=0.708), ethnicity (p=0.522) and job title (p=0.828) were not significantly associated with self-reported handwashing. Sixty seven (88%) respondents indicated they had received some form of handwashing training, most frequently provided by infection control staff (n=25; 37%).
The sample reported that they observed handwashing recommendations approximately 77% of the time.
A regression model was used to explore the relative importance of the potential covariates (possible predictors) of handwashing behaviour. All assumptions of linear regression were met. A correlational analysis was used to determine which variables to include in the regression analysis: four were included (perceived importance of handwashing, perceived risk to self, perceived risk to others and workplace assists handwashing), from which a significant model emerged. The two variables that significantly predicted self-reported handwashing were “perceived importance of handwashing” and “workplace assists handwashing”.
These results were perhaps unsurprising. However, it was felt these variables may be intervening in the relationship between self-reported handwashing and other variables measured in the questionnaires. Further correlational and regression analyses were performed to examine covariates of both perceived importance of handwashing and workplace assists handwashing in turn. Again, all assumptions of linear regression were met. For perceived importance of handwashing, a significant model emerged: the only significant covariate was nurses’ perceptions regarding transmission of infection. The amount of occupational stress nurses reported and whether or not they had received training in handwashing were the only significant covariates of their perception of the degree to which their workplace assisted handwashing.
Nurses in this study were more likely to wash their hands if they perceived it to be important and if they thought their workplace helped them in doing so. Secondary regression models show that other factors should be considered when creating interventions to improve handwashing rates. The best covariate of perceived importance was how strongly a nurse believed that poor handwashing practice contributes to infection transmission. This issue should be emphasised in all interventions.
The organisation’s role in providing a supportive workplace should also be considered. Nurses who saw their employers as supportive were more likely to observe handwashing guidelines. Also, occupational stress was seen to reduce the perception of having a supportive employer. It is important to recognise that organisations need to both facilitate handwashing and to protect staff from factors that have a negative impact, such as occupational stress.
Receiving training in handwashing was not directly related to self-reported handwashing, though results suggest that those nurses who had received training were significantly more likely to regard their employers as being helpful. This variable was itself observed to be associated with self-reported handwashing: it may be that employers who protect time for such training create a perception among nurses that they are interested in their wellbeing.
Although the importance of self-efficacy in health behaviour change literature is well reported, this study failed to find any association between self-efficacy and self-reported handwashing. Some potential explanations include the relatively simple nature of handwashing as a behaviour: it may be that self-efficacy becomes more important as the complexity of a behaviour increases. Equally, further exploration using a self-efficacy measure specific to handwashing may be more sensitive to any potential association between these variables. It should also be noted that this sample reported high levels of self-efficacy - there may have been insufficient variation in observed scores to establish potential for discrimination.
Several issues limit the extent to which these results can be generalised. The sample was self-selecting and it is not possible to claim that the opinions of those who decided to participate are representative of those who did not. However, it should be noted that those who did participate were experienced employees (average of 12.9 years in the NHS). The sample was mostly comprised of women and was small in size, which again limits the representativeness of the results.
This study demonstrates that in this sample, psychological variables such as perception of importance, perception of workplace support, occupational stress and perception of risk were important covariates of handwashing behaviour.
- This article is an edited version of a paper originally published in the Journal of Infection Prevention (Hanna et al, 2009).
We would like to thank those nurses who took the time to participate in this study.
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