Major articleSystematic qualitative literature review of health care workers' compliance with hand hygiene guidelines
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)
- et al.
Cost of bloodstream infections
Am J Infect Control
(2008) - et al.
‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene
J Hosp Infect
(2007) - et al.
Role of hand hygiene in healthcare-associated infection prevention
J Hosp Infect
(2009) - et al.
Gender influences handwashing rates in the critical care unit
Am J Infect Control
(2001) - et al.
Hand hygiene non-compliance among intensive care unit health care workers in Aseer Central Hospital, south-western Saudi Arabia
Int J Infect Dis
(2013) - et al.
Effectiveness of a hospital-wide programme to improve compliance with hand hygiene
Lancet
(2000) - et al.
Prevalence of and risk factors for non-compliance with glove utilization and hand hygiene among obstetrics and gynaecology workers in rural China
J Hosp Infect
(2005) - et al.
Measuring handwashing performance in health service audits and research studies
J Hosp Infect
(2007) - et al.
Qualitative research methods: key features and insights gained from use in infection prevention research
Am J Infect Control
(2008) - et al.
Hand hygiene compliance: the elephant in the room
Healthc Infect
(2013)
Exploring the hand hygiene competence of student nurses: a case of flawed self assessment
Nurse Educ Today
Focus group data as a tool in assessing effectiveness of a hand hygiene campaign
Am J Infect Control
Medical students' perceptions of their role as covert observers of hand hygiene
Am J Infect Control
Physicians and hand hygiene practice: a focus group study
J Hosp Infect
Appraising the quality of qualitative research
Midwifery
Optimisation of infection prevention and control in acute health care by use of behaviour change: a systematic review
Lancet Infect Dis
A survey on handwashing practices and opinions of healthcare workers
J Hosp Infect
Can the emotion of disgust be harnessed to promote hand hygiene? Experimental and field-based tests
Soc Sci Med
The infection control audit: the standardized audit as a tool for change
Am J Infect Control
Behavioral interventions to improve infection control practices
Am J Infect Control
Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections
Am J Infect Control
Report on the burden of endemic healthcare-associated infection worldwide 2011
WHO guidelines on hand hygiene in health care 2009
Healthcare workers' hand decontamination practices: compliance with recommended guidelines
J Adv Nurs
No time for handwashing. Handwashing versus alcoholic rub: can we afford 100% compliance?
Infect Control Hosp Epidemiol
Hand hygiene compliance: exploring variations in practice between hospitals
Nurs Times
An organizational climate intervention associated with increased handwashing and decreased nosocomial infections
Behav Med
Systematic field observation
Ann Rev Sociol
Recall bias can be a threat to retrospective and prospective research designs
The Internet Journal of Epidemiology
Competing paradigms in qualitative research: theories and issues
Qualitative research and Cochrane reviews
Interventions to improve hand hygiene compliance in patient care
Cochrane Database Syst Rev
Systematic review of studies on compliance with hand Hygiene guidelines in hospital care
Infect Control Hosp Epidemiol
Using qualitative metasummary to synthesize qualitative and quantitative descriptive findings
Res Nurs Health
Classifying the findings in qualitative studies
Qual Health Res
Meta-synthesis of qualitative findings
Qual Health Res
Cited by (109)
Evaluating methods for the use and decontamination of needleless connectors: A qualitative inquiry
2022, Infection, Disease and HealthThe Coat Hook Analogy and the Precision Implementation Approach® Solution
2022, Journal of Perianesthesia NursingHand hygiene compliance among healthcare workers before and during the COVID-19 pandemic
2022, American Journal of Infection ControlHealthcare worker mental models of patient care tasks in the context of infection prevention and control
2022, Infection Control and Hospital Epidemiology
Conflicts of interest: None to report.