Major article
Systematic qualitative literature review of health care workers' compliance with hand hygiene guidelines

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Highlights

  • Perceptions of the hospital work environment and behavioral motivation appear to influence health care workers' compliance with hand hygiene guidelines.

  • The findings of the systematic review are consistent with findings from the quantitative research.

  • Use of theoretical framework in relation to investigating health care workers' compliance with hand hygiene guidelines allows a shared understanding of the dimensions being studied.

Background

Acquisition of a health care–associated infection is a substantial risk to patient safety. When health care workers comply with hand hygiene guidelines, it reduces this risk. Despite a growing body of qualitative research in this area, a review of the qualitative literature has not been published.

Methods

A systematic review of the qualitative literature.

Results

The results were themed by the factors that health care workers identified as contributing to their compliance with hand hygiene guidelines. Contributing factors were conceptualized using a theoretical background. This review of the qualitative literature enabled the researchers to take an inductive approach allowing for all factors affecting the phenomenon of interest to be explored. Two core concepts seem to influence health care workers' compliance with hand hygiene guidelines. These are motivational factors and perceptions of the work environment. Motivational factors are grounded in behaviorism, and the way in which employees perceive their work environment relates to structural empowerment.

Conclusion

Noncompliance with hand hygiene guidelines remains a collective challenge that requires researchers to adopt a consistent and standardized approach. Theoretical models should be used intentionally to better explain the complexities of hand hygiene.

Section snippets

Methods

Based on the work of Sandelowski,22, 23 we sought to systematically identify, explore, and describe similar qualitative studies to gain a better understanding of their shared meanings. This involved systematically searching, collating, and summarizing results of the studies to establish if there were links. The emergent themes were discussed and the characteristics of included studies were considered before a consensus was reached on the themes. Rigor was maintained throughout each stage so

Data sources and search strategy

The databases MEDLINE (PubMed), Embase, and Cumulative Index to Nursing and Allied Health Literature were searched from 2000-June 2014. The search terms used were as follows: “qualitative research,” “qualitative studies,” “hand washing,” “hand hygiene,” “intervention,” “barriers,” and “inhibitors.” These terms were used using the Boolean operators “and” and “or”. Searches were limited to English language studies only. Selected studies provided primary qualitative data from health care workers

Study selection

Twenty-five articles were reviewed independently by the researchers (M.P.S., R.O'C., S.A.C.), and the final selection (n = 10) was agreed on following debate and discussion. The studies were carried out in Canada (n = 3), the United Kingdom (n = 2), Australia (n = 2), The Netherlands (n = 1), the United States (n = 1), and Taiwan (n = 1). Participants included doctors, nurses, allied health professionals, and social workers. When the sample sizes were combined, a total of 415 health care

Quality assessment

Two reviewers (M.P.S., R.O'C.) independently appraised the studies using a standard quality assessment scale.36 Differences of opinion were resolved through discussion, and appraisal was completed by a third reviewer (S.A.C.). All the studies with the exception of 1 study27 had methodologic weaknesses. Common flaws included a lack of a theoretical framework, author reflexivity, and inadequate information regarding the interpretation and analysis of the data. The studies were also appraised

Data extraction, management, and analysis

Original qualitative data regarding health care workers' compliance with hand hygiene guidelines were extracted, transcribed to a Microsoft Word document (Microsoft, Redmond, WA), and imported into NVivo10 qualitative data management software (QSR International, Doncaster, Australia) (M.P.S.). Two researchers independently analyzed the data (M.P.S., S.A.C.) by reading it repeatedly, identifying and coding recurrent themes as they emerged. These codes were compared and contrasted and agreed on

Results

The results are presented in Figure 2.

Themes identified

From systematically reviewing these 10 studies, the factors that impact on health care workers' compliance with hand hygiene guidelines fall into 2 broad categories: motivational factors and perceptions of the work environment. Motivational factors include social influences, the acuity of patient care, self-protection, and use of cues. Perceptions of the work environment include resources, knowledge, information, and organizational culture.

Motivational factors

The motivational factors that influenced health care workers' compliance with hand hygiene guidelines were as follows: social influences, acuity of care, self-protection, and use of cues.

Perceptions of the work environment

The way that health care workers' perceived their work environment was linked to their compliance with hand hygiene guidelines. The aspects of the work environment that influenced health care workers' compliance with hand hygiene guidelines were resources, knowledge, information, and organizational culture.

Discussion

We undertook this systematic review of the qualitative literature to ascertain if we could gain a new understanding of the factors that influence health care workers' compliance with hand hygiene guidelines. Systematic reviews of quantitative literature have been undertaken.20, 21 This is the first review that has systematically explored qualitative literature only on this topic. The findings are in keeping with the larger body of quantitative research on health care workers' compliance with

Limitations

This review revealed a lack of quality empirical qualitative research in relation to health care workers' compliance with hand hygiene guidelines. There are methodologic issues with almost all the included studies in relation to credibility, transferability, and confirmability. Although all the studies included initial qualitative data, none of the studies further explored why the participants felt they way they did regarding hand hygiene practices and compliance. The exclusion of studies

Conclusion

In conclusion, using a theoretical perspective provides the philosophical stance that informs the methodology of the research, provides a context, and grounds it in logic.70 It provides a vocabulary to describe the key features of the targeted inquiry71 and a framework within which to represent the dimensions that unifaceted studies address.72 Using a conceptual framework thereby contributes to building a cumulative understanding of the topic under investigation.58 In this review, by

References (72)

  • M. Cole

    Exploring the hand hygiene competence of student nurses: a case of flawed self assessment

    Nurse Educ Today

    (2009)
  • M. Thomas et al.

    Focus group data as a tool in assessing effectiveness of a hand hygiene campaign

    Am J Infect Control

    (2005)
  • S.C. Pan et al.

    Medical students' perceptions of their role as covert observers of hand hygiene

    Am J Infect Control

    (2014)
  • J. Jang et al.

    Physicians and hand hygiene practice: a focus group study

    J Hosp Infect

    (2010)
  • D. Walsh et al.

    Appraising the quality of qualitative research

    Midwifery

    (2006)
  • R. Edwards et al.

    Optimisation of infection prevention and control in acute health care by use of behaviour change: a systematic review

    Lancet Infect Dis

    (2012)
  • A.D. Harris et al.

    A survey on handwashing practices and opinions of healthcare workers

    J Hosp Infect

    (2000)
  • R. Porzig-Drummond et al.

    Can the emotion of disgust be harnessed to promote hand hygiene? Experimental and field-based tests

    Soc Sci Med

    (2009)
  • E.A. Bryce et al.

    The infection control audit: the standardized audit as a tool for change

    Am J Infect Control

    (2007)
  • E.K. Kretzer et al.

    Behavioral interventions to improve infection control practices

    Am J Infect Control

    (1998)
  • J. Al-Tawfiq et al.

    Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections

    Am J Infect Control

    (2013)
  • B. Allegranzi et al.

    Report on the burden of endemic healthcare-associated infection worldwide 2011

    (2011)
  • WHO guidelines on hand hygiene in health care 2009

    (2009)
  • S. Creedon

    Healthcare workers' hand decontamination practices: compliance with recommended guidelines

    J Adv Nurs

    (2005)
  • A. Voss et al.

    No time for handwashing. Handwashing versus alcoholic rub: can we afford 100% compliance?

    Infect Control Hosp Epidemiol

    (1997)
  • S. Creedon et al.

    Hand hygiene compliance: exploring variations in practice between hospitals

    Nurs Times

    (2008)
  • E. Larson et al.

    An organizational climate intervention associated with increased handwashing and decreased nosocomial infections

    Behav Med

    (2000)
  • G. McCall

    Systematic field observation

    Ann Rev Sociol

    (1984)
  • E. Hassan

    Recall bias can be a threat to retrospective and prospective research designs

    The Internet Journal of Epidemiology

    (2005)
  • E. Guba et al.

    Competing paradigms in qualitative research: theories and issues

  • J. Noyes et al.

    Qualitative research and Cochrane reviews

  • D.J. Gould et al.

    Interventions to improve hand hygiene compliance in patient care

    Cochrane Database Syst Rev

    (2010)
  • V. Erasmus et al.

    Systematic review of studies on compliance with hand Hygiene guidelines in hospital care

    Infect Control Hosp Epidemiol

    (2010)
  • M. Sandelowski et al.

    Using qualitative metasummary to synthesize qualitative and quantitative descriptive findings

    Res Nurs Health

    (2007)
  • M. Sandelowski

    Classifying the findings in qualitative studies

    Qual Health Res

    (2003)
  • L.A. Jensen et al.

    Meta-synthesis of qualitative findings

    Qual Health Res

    (1996)
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    Conflicts of interest: None to report.

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