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Running Head: HANDWASHING

Handwashing: Changing Nurses Behavior


Kendra Calonita, Shamila Hashimi, Estelle Maassen, Kathleen Minor
Western Washington University

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Handwashing: Changing Nurses Behavior

Purpose/Aim: The research paper was an examination of the current evidence on how to change
nurses behavior regarding hand hygiene. Additionally, research was conducted to examine the
barriers to nurses performing hand hygiene and the consequences of poor compliance.
Rationale/Conceptual Basis/Background: About 1 in 25 hospital patients have a least one
healthcare-associated infection. There were an estimated 722,000 HAIs in U.S. hospitals in
2011, and about 75,000 hospital patients with HAIs died during their hospitalizations. Increased
hand hygiene among the nursing staff can significantly reduce these statistics and also reduce
hospital cost. Both Medicare and Medicaid will not reimburse hospitals when patients develop
HAIs, which increases the importance for hospitals to develop ways for nurses to comply with
hand washing.
Methods: Using previously published research, the 6 quantitative and 1 qualitative studies were
critiqued and used to gather information on changing nurse hand hygiene behavior.
Results: Within several of the quantitative studies, information concerning psychological models
aimed to change nurses behavior was discussed. The following models were mentioned: the
transtheoretical model (TTM), or the theory of planned behavior (TPB), and also the 6-section
strategy wheel. The TTM or TPB model focused on the cognitive/logical aspect of behavioral
change. The 6-section strategy wheel focused on the importance of appealing to both the logical
and emotional side of nurses reasoning. The 6-section strategy wheel found that focusing on
only one aspect decreases nurses adherence to handwashing. The qualitative study found that
there are several advantages and disadvantages in implementing the five moments of hand
hygiene. Advantages include protection of both patients and self while disadvantages are
increased time in patient room and increased skin irritation. Barriers found to decrease hand
hygiene compliance were emergency situations, decreased availability of hand hygiene products
or sinks, lack of education and understanding, understaffing, and lack of commitment by facility
leadership.
Implications: Both nurse managers and nurse leaders need to provide nurses with education on
the importance of hand washing and its effect in reducing the number of HAIs. Providing nurses
with education, reminders/feedback, administrative support and constant access to either hand
sanitizer or soap and water is necessary in order to change behavior.

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Hand hygiene reduces the risk of transmission of microorganisms. Applying this essential
skill to all patients receiving care is one of the first and foremost practices nurses learn in the
beginning of their curriculum. As important as this basic skill is, it is easily forgotten or
improperly executed leading to an increased risk of health care associated infections. The World
Health Organization (WHO) has adopted new guidelines for hand hygiene that include adherence
to 5 critical moments for hand hygiene for patient care: before touching a patient (Moment 1),
before a procedure (Moment 2), after a procedure (Moment 3), after touching a patient (Moment
4), and after touching a patients surroundings (Moment 5) (White, Jimmieson, Obst, Graves,
Barnett, Cockshaw, Paterson, 2015). How do we change nurses behavior to increase compliance
with hand hygiene? Nurses have the most physical contact with patients, therefore, implementing
intervention strategies that can improve and encourage nurses behavior towards hand hygiene
measures needs to be enforced in the hospital setting.
Synthesis of the Literature
Barriers to Compliance
Barriers that lead to low compliance of hand hygiene include; emergency situations, skin
irritations, lack of availability of hand hygiene products or sinks, lack of education and
understanding, lack of time, understaffing, and lack of commitment by facility leadership (White,
et al. 2015). Hospital administrators and managers need to be aware of these barriers that cause
nursing staff to be uncooperative with hand hygiene. Hand hygiene is not emphasized enough for
nurses to adhere to the skill in clinical practice. The importance of hand hygiene must be taught
to nurses in a way that will not only change their behavior, but their perspective. Lack of support
and commitment among nurses and management are other major barriers to proper hand hygiene

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(Huis, Hulscher, Adang, VanAchterberg, & Schoonhoven, 2013). Nursing leaders need to be
educated on strategies to significantly improve hand hygiene compliance by understanding the
consequences of poor hand hygiene.
Consequences of Poor Hand Hygiene
Poor hand hygiene compliance is costly for the United States. The estimated annual cost
of hospital acquired infections (HAIs) is $9.8 billion and 99,000 deaths, therefore, increasing
hand hygiene compliance decreases HAIs significantly (Taylor, 2015). Despite the need for
compliance, nurses are continuing to overlook the consequences due to the lack of education.
Across hospital settings, patients can acquire bloodstream infections, surgical site infections,
urinary tract infections, chest/respiratory infections or gastrointestinal infections (WHO.com).
The simplest and low cost action taken by nurses to decrease the spread of infection is good hand
hygiene practice. Proper hand hygiene may not be the only measure taken to reduce HAIs, but
scientific evidence proves that most microbes are transmitted to patients by the hands of
healthcare workers (WHO.com).
Changing Nurses Behavior
The WHO introduced My Five Moments for Hand Hygiene (5MHH) to promote hand
hygiene and minimize the risk for HAIs (Eiamsitrakoon, Apisarnthanarak, Nuallaong,
Khawcharoenporn, & Mundy, 2013). Behavior change using the transtheoretical model (TTM) or
the theory of planned behavior (TPB) may promote healthy behavioral change among nurses
hand hygiene compliance (Eiamsitrakoon, et al. 2013). There are five stages of TTM which
include; precontemplation (1), contemplation (2), preparation (3), action (4), and maintenance
(5). Precontemplation refers to having no intention of changing behavior. Contemplation is when

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the individual is in the beginning stages of making a change. Preparation is when the change this
person wants to make is going to be scheduled. Action is when the person is engaging in
behavior change. And finally, maintenance is the stage of actual, continual behavior change.
Overall, this theory highlights one psychological pathway in which nurses change or modify
their hand hygiene behavior (Al-Tawfiq & Pittet, 2013).
The TPB is an intrapersonal theory that involves: attitude toward behavior, subjective
norms, and perceived behavioral control (Eiamsitrakoon et. al, 2013). TPB is based on the idea
that rational thought precedes behavior and that providing the necessary rational information to
an individual will likely lead to behavior change (Taylor, 2015). Humans are more likely to
change their behavior if they have a sense of control. The control of behavior is largely
influenced by internal and external factors. An in-hospital study on hand-washing predicted that
nurses compliance was determined by the benefit of the action, peer pressure of physicians and
administrators, and having positive role models (Al-Tawfiq & Pittet, 2103). The TPB model links
the notion of attitudes, control, and internal/external factors to result in modification of the
behavior. By utilizing the TPB model, nurse leaders and management can improve upon the
process of modifying nurses hand washing behavior (Al-Tawfiq & Pittet, 2013).
Another recent model of behavior and communication integrates transmission and
ritual communication.
The purpose of informational communication is to deliver information, knowledge, and ideas
to others in a way that appeals to ones cognition or logic. Transformation, or ritual view,
communication focuses on peoples beliefs, attitudes, self-image, and perceptions; focusing on
ones emotions or senses (Taylor, 2015, pg. 1167)

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In the article by Taylor (2015), a 6-section strategy wheel is presented and theorizes 6
different ways to influence behavior change, acknowledging that each individual may have a
different way of being influenced. The strategy wheel is divided into two sections, the left being
the informational or rational side, and the right being the transformational or emotional side.
Within the left side there are three segments: routine, acute need and rational. The routine
section focuses on habits individuals form over time due to repetitive conditioning. The acute
need section looks at an individuals instant reaction to a certain activity. The rational section
concentrates on appealing to an individuals logic and rational thinking. The right side of the
strategy wheel also consists of the three segments: ego, social and sensory. The ego section
delves into a persons tendency in appealing to self. In the social section; establishing,
preserving, and protecting relationships is the priority. Lastly, within the sensory section,
attention is directed toward appealing to the individuals fifth sense. This strategy wheel may
influence hand hygiene compliance positively by causing nurses to acknowledge their form of
learning so that acquiring this habit becomes a repetitive practice.
Conflicting Findings
Although all research study findings support the significance of hand washing and its role
in preventing HAIs, different theories and practices appear to yield better results pertaining to
compliance. According to Taylor (2016), using theories to motivate nurses both rationally and
emotionally versus appealing in a singular fashion is found to produce better outcomes.
Although, Erkan et al. believe that improving results of hand washing compliance can be
achieved by direct observation and feedback by utilizing a single strategy: education (2011).
Although direct observation is a simple and effective tool for monitoring compliance, a concept
known as the Hawthorne Effect could inaccurately represent the percentage of hand hygiene

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compliance (Hagel, Reischke, Kesselmeier, Winning, Gastmeier, & Brunkhorst, 2015). The
Hawthorne Effect refers to when compliance increases not because of education related to the
importance of hand hygiene, but due to the knowledge of being monitored and the fear of being
singled out for poor hand hygiene (Hagel et al, 2015).
Overall Perspective & Gaps
There are considerable gaps between healthcare workers 5 moments of hand hygiene
(5MHH) and observed behavior in studies. Larger studies need to be implemented in multiple
hospital settings for a better and more expansive understanding of hand hygiene behavioral
commitments versus observed behavior (Eiamsitrakoon et. al, 2013). Further studies should
include data on observed hand-washing behavior before and after training programs to evaluate
the effectiveness of hand-washing knowledge translated into behavior (Erkan, Findik, & Tokuc,
2011). Although behavioral theories have been examined and thoroughly researched, the next
step of applying these theories into the hospital setting needs to be explored in order to determine
which theory provides better adherence to hand-hygiene compliance.
Evaluation Plan
According to the WHO, improved compliance was better achieved by education,
reminders, feedback, administrative support, and access to alcohol-based hand rub (Taylor,
2015). Overall, planned communication between administrators and nurses is an essential part of
these interventions intended at improving hand hygiene. It is also recommended that handwashing training programs be implemented for better results of hand hygiene compliance by
improving the behavior and knowledge of nurses at all stages of their careers (Erkan, Findik, &
Tokuc, 2011). Theory-based behavioral models, such as the theory of planned behavior that

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facilitate a positive attitude towards the 5MHH were associated with better compliance.
Management auditing of hand hygiene technique, electronic monitoring and direct observation
may also prove beneficial effects to increase compliance (Hagel et. al, 2015).
Implications of Change
Currently, an increasingly common pathway to nursing involves first attaining a certified
nursing assistant license. During the nursing assistant certification process, hand hygiene is
arguably the first skill learned and demonstration of proper hand hygiene is required to achieve
licensure. Once licensure is granted, proper hand hygiene is introduced during the orientation
period and becomes a rarely revisited skill. As a nursing assistant advances into an associates of
nursing program, proper hand hygiene technique is briefly revisited and often not reexamined.
As a nurse begins their career, hand hygiene is either fleetingly mentioned during hospital
orientation or not at all because it is expected that after years of training, proper hand hygiene is
a skill expected to be mastered.
Assumed mastery of proper hand washing technique at every level of nursing needs
reevaluation. According to the Center for Disease Control and Prevention, on any given day, 1 in
25 patients in the hospital setting has at least one healthcare-associated infection. Posters posted
in staff bathrooms on proper hand hygiene technique is not adequate and ongoing education
regarding the importance of hand washing is a necessity in reducing hospital acquired infections.
An abundance of research concerning the psychology behind changing nurses behavior
exists. Instead of implementing a singular strategy, a wide variety of strategies combined can
increase awareness and compliance of the 5MHH while decreasing the spread of infection.
Through continuing education, direct hand washing observation, electronic monitoring, and

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utilization of different behavioral strategies, nurses today become excellent role models for
future nurses in the quest to eliminate hospital acquired infections.

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References

Al-Tawfiq, J. A., & Pittet, D. (2013). Improving had hygiene compliance in healthcare settings
using behavior change theories: reflections. Teaching and Learning in Medicine: An
International Journal. 25:4, 374-82. doi: 10.1080/10401334.2013.827575
Eiamsitrakoon, T., Apisarnthanarak, A., Nuallaong, W., Khawcharoenporn, T., & Mundy, L.M.
(2013). Hand hygiene behavior: Translating behavioral research into infection control
practice. Infection Control and Hospital Epidemiology, 34(11), 1137-1145. doi:
10.1086/673446
Erkan, T., Findik, U.Y., & Tokuc, B. (2011). Hand-washing behavior and nurses knowledge after
a training programme. International Journal of Nursing Practice, 17, 464-469. doi:
10.1111/j.1440-172X.2011.01957.x
Hagel, S., Reischke, J., Kesselmeier, M., Winning, J., Gastmeier, P., Brunkhorst, F. M., & ...
Pletz, M. W. (2015). Quantifying the Hawthorne Effect in Hand Hygiene Compliance
Through Comparing Direct Observation With Automated Hand Hygiene
Monitoring. Infection Control & Hospital Epidemiology, 36(8), 957-962 6p.
doi:10.1017/ice.2015.93
Huis, A., Hulscher, M., Adang, E., Grol, R., vanAchterberg, T., Schoonhoven, L. (2013). Costeffectiveness of a team and leaders-directed strategy to improve nurses adherence to
hand hygiene guidelines: A cluster randomized trial. International Journal of Nursing
Studies. 50(4): 518-526.
Taylor, R.E. (2015). The role of message strategy in improving hand hygiene compliance rates.
American Journal of Infection control. 43, 1166-70
White, K.M., Jimmieson, N.L., Obst, P.L., Graves, N., Barnett, A., Cockshaw, W., Paterson,
D. (2015). Using a theory of planned behavior framework to explore hand hygiene beliefs

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at the 5 critical moments among Australian hospital-based nurses. BMC Health Services
Research, 15, 1-9. doi: 10.1186/s12913-015-0718-2

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