| |

Received: 17 February 2018    Revised: 20 September 2018    Accepted: 17 October 2018

DOI: 10.1111/jocn.14703

ORIGINAL ARTICLE

Interventions to increase hand hygiene compliance in a tertiary

university hospital over a period of 5 years: An iterative
process of information, training and feedback

Magdalena Hoffmann1,2,3 | Gerald Sendlhofer1,2  | Gudrun Pregartner4 | 

Veronika Gombotz1 | Christa Tax5 | Renate Zierler6 | Gernot Brunner2,5

1
Executive Department for Quality and Risk
Management, University Hospital Graz,
Graz, Austria
2
Research Unit for Safety in Health, c/o
Division of Plastic, Aesthetic and
Reconstructive Surgery, Department of
Surgery, Medical University of Graz, Graz,
Austria
3 adherence to the “My five moments” (M5M) for HH varies significantly within organi-
Department of Internal Medicine, Medical
University of Graz, Graz, Austria
4
Institute for Medical Informatics, Statistics
and Documentation, Medical University of
Graz, Graz, Austria
5
University Hospital Graz, Graz, Austria
6
Executive Department for Hygiene
Aspects, University Hospital Graz, Graz,
Austria
Correspondence
Gerald Sendlhofer, LKH-Univ. Klinikum
Graz und Medizinische Universität Graz,
Stabsstelle QM-RM, Graz, Austria.
Email: gerald.sendlhofer@medunigraz.at
Abstract
Aims and objective: To explore whether an iterative process of information and train-
ing paired with a feedback system to observed healthcare professionals and the re-
spective management improves hand hygiene (HH) compliance.
Background: Healthcare-­associated infections are a major risk for patient safety, and
sations as well as within healthcare professional groups. Identified barriers in a base-
line survey revealed the need of more information, training, repetitive compliance
measurements and feedback to all healthcare professionals.
Design: A quality improvement project using the method of direct observation of
healthcare professionals in nonsurgical and surgical wards.
Methods: Between 2013 and 2017, 6,009 healthcare professionals were in-
formed and trained, and HH compliance measurements were performed by hy-
giene experts. Compliance measurement results were documented in an online
tool to give an immediate feedback to observed healthcare professionals.
Additionally, a report was forwarded to the management of the respective de-
partment to raise awareness. Compliance rates per year were descriptively sum-
marised. The research and reporting methodology followed SQUIRE 2.0.
Results: In total, 84 compliance measurements with 19,295 “M5M for HH” were ob-
served in 49 wards. Overall, mean HH compliance increased from 81.9 ± 5.2% in
2013 to 94.0 ± 3.6% in 2017. Physicians’ HH compliance rate improved from
69.0 ± 16.6% to 89.3 ± 6.6%, that of nurses from 86.0 ± 6.9% to 96.4 ± 3.1%, and that
of others from 60.5 ± 27.9% to 83.8 ± 20.2%. All M5M for HH (#1–#5) increased over
the study period (#1: +16.9%; #2: +20.5%; #3: +7.6%; #4: +5.9%; #5: +12.7%).
Conclusions: Results demonstrated that an iterative process of information, training,
observation and feedback over a period of 5 years can be successful in increasing HH
compliance. Positive trends were observed for HH compliance rates across all health-
care professional groups as well as for all M5M for HH.
KEYWORDS
behaviour, compliance, quality and safety, training

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction
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© 2018 The Authors. Journal of Clinical Nursing Published by John Wiley & Sons Ltd

J Clin Nurs. 2018;1–8. wileyonlinelibrary.com/journal/jocn |  1

  
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2       HOFFMANN et al.
1 |  I NTRO D U C TI O N
Healthcare-­associated infections (HAI) are a major risk for patient
safety and cause a serious disease burden worldwide with enormous
economic impact (Ott, Saathoff, Graf, Schwab, & Chaberny, 2013;
Pereira et al., 2017; Sendlhofer, Brunner, et al., 2015; Sendlhofer,
Krause, et al., 2015; World Health Organization (WHO), 2009).
Adherence to the “My Five Moments for Hand Hygiene” (M5M for
HH) helps to avoid a certain amount of HAI and, thereby, hygienic
hand disinfection with alcohol-­based hand rub is regarded as the
most effective measure in the prevention of HAI (Kampf, Löffler, &
Gastmeier, 2009; von Lengerke et al., 2017). Recently, it was also
demonstrated that there is an association between increased HH
compliance rates and decreasing HAI rates (Sickbert-­Bennett et al.,
2016). Despite the theoretical simplicity of performing HH accord-
ing to the M5M for HH and the known effect on helping to prevent
HAI, HH compliance rates vary significantly between organisations,
within healthcare professional groups, and with respect to each of
the M5M for HH (Azim, Juergens, & McLaws, 2016; Pereira et al.,
2017; Tartari et al., 2017). Low HH compliance rates are still a
prevalent phenomenon with varying causes and barriers (Erasmus
et al., 2010; Kampf et al., 2009; von Lengerke et al., 2017; Mahida,
2016; Pittet et al., 2004; Wetzker et al., 2016). Therefore, changing
the paradigm to encourage those who are sceptical about the im-
portance of HH is an important task for the future (Gould, Navaïe,
Purssell, Drey, & Creedon, 2017).
2 |  BAC KG RO U N D
In 2012, facilitators, barriers and level of knowledge with respect
to the M5M for HH by means of a baseline survey were identified
(Sendlhofer, Brunner, et al., 2015; Sendlhofer, Krause, et al., 2015).
Thereafter, a Styrian-­wide HH-­c ampaign according to the guide-
lines of the German national HH-­c ampaign was initiated. In 2013,
additional compliance measurements in wards with subsequent
oral feedback to healthcare professionals as well as summaris-
ing protocols of the compliance measurement were implemented.
According to the literature, an in-­h ouse goal of 80% HH compli-
ance rate was defined for all healthcare professionals and a level
of 90% HH compliance was rated as very good (Bradley, Holden,
& Garvey, 2017; Sickbert-­B ennett et al., 2016; WHO, 2009). The
overall goal was to implement HH measurements not only as
a campaign for a certain period of time, but to establish it as a
permanent repetitive managerial tool aiming to follow the Plan-­
Do-­C heck-­Act-­c ycle (PDCA). If the minimum goal of 80% HH com-
pliance rate was not reached, additional educational measures had
to be performed by the respective healthcare professional groups.
This iterative process was introduced according to the model of
the WHO (Chen et al., 2016; Neo, Sagha-­Z adeh, Vielemeyer, &
Franklin, 2016; WHO, 2009). It was also the aim to activate man-
agers as they should function as positive role models for their
colleagues. They should be enabled to influence and react to the
What does this paper contribute to the wider global
clinical community?
• An iterative process of repetitive information, training
and feedback of healthcare professionals (n = 6,009)
over a constant period of time increased awareness con-
cerning hand hygiene (HH) behaviours.
• A total of 19,295 observed “My five moments for HH”
over a period of 5 years showed continuous improve-
ment in HH for all healthcare professionals and for all
“My five moments for HH.”
• Overall, already high HH compliance increased from
81.9 ± 5.2% in 2013 to 94.0 ± 3.6% in 2017.
compliance measurement results in the respective department in
order to further improve, or to keep up a certain high level of HH
compliance (Hugonnet, Perneger, & Pittet, 2002).
The upper management of the University Hospital Graz ranked
insufficient HH as a major risk (Sendlhofer, Brunner, et al., 2015;
Sendlhofer, Krause, et al., 2015). Therefore, an iterative process
of repetitive information, training and compliance measurements
paired with a feedback system to managers and healthcare profes-
sionals was implemented. If these measures influenced HH habits
and thereby compliance rates, the development of HH compliance
rates from 2013–2017 was observed in wards.
3 | M E TH O DS
3.1 | Baseline survey
In 2012 and 2013, a baseline survey among healthcare profession-
als (physicians, nurses and others such as physiotherapists and di-
eticians) revealed a bundle of barriers regarding HH, such as lack
of knowledge, environmental barriers or perceived barriers rang-
ing from not having enough time for HH, not seeing any reason for
HH or simply forgetting to clean one’s hands (Sendlhofer, Brunner,
et al., 2015; Sendlhofer, Krause, et al., 2015). Thereafter, environ-
mental audits took place to implement an adequate infrastructure
to eliminate environmental barriers such as not easily accessible or
altogether missing alcohol-­based hand rub dispensers (Sendlhofer,
Brunner, et al., 2015; Sendlhofer, Krause, et al., 2015).
3.2 | Information and training
To overcome knowledge barriers, promotional material of the
German Clean Hands Campaign was used to raise general awareness
for the hospital-­wide HH-­campaign. This included a HH-­poster cam-
paign in each ward or leaflets which were distributed to all health-
care professionals as well as administrative personal. Additionally,
all healthcare professionals received twice a year an in-­house e-­
newsletter with relevant hygiene information.
HOFFMANN et al. |
      3

TA B L E   1   Overview of information and training tools for trainings. This e-­learning unit has to be performed in a repetitive
healthcare professionals manner every 2 years (for further information see Table 1).
General tools
Leaflets for HH-­poster for Additional alcohol-­based
3.3 | Compliance measurement
healthcare wards hand rub dispensers for
professionals patients and visitors Evaluating the M5M for HH compliance (#1 before touching a pa-
Information campaign for healthcare professionals tient, #2 before clean/aseptic procedures, #3 after body fluid
Action Day for HH-­e-­ HH-­training video exposure/risk, #4 after touching a patient and #5 after touching pa-
HH newsletter tient surroundings) through direct observation by hygiene experts
Occasion-­related Workshops by hygiene experts using UV started in 2013 and was part of a consecutive roll-­out plan involv-
training blacklight (Didaktobox)
ing all wards in a repetitive mode (Sax, Uçkay, Richet, Allegranzi, &
opportunities
Pittet, 2007; Sax, Allegranzi, et al., 2007; WHO 2018) (Supporting
Mandatory HH-­trainings
Information Figure S1).
Face-­to-­face HH-­e-­learning HH standard operating
Hygiene experts strictly followed the guideline for conduct-
HH-­in-­house (2 units) procedures
training ing compliance measurements issued by the German Clean Hands
Campaign (“Anleitung zur Beobachtung der Händedesinfektion
HH-­report for Immediate oral feedback after compliance
the measurement (Bestimmung der Compliance),” n.d.). Each of the M5M for HH was
management at least observed for 20 times during one compliance measurement
Students’ teaching and at least 150 M5M for HH had to be observed in each ward.
Lecture for Lecture for Lecture for medical Consistency of evaluation was maintained as observations within
human medicine nursing technical assistants each ward were performed by the same hygiene expert between
students students 2013–2017.
For example, 31 possible M5M for one indication were observed
and 24 correct HH were performed (corresponding to 77% compli-
Yearly, a so-­called Action Day for HH conference was organised by ance). Observational results were immediately documented in an on-
so-­called hygiene experts (corresponding to infection control agents) line tool, which was connected via WIFI to the “National Reference
to inform healthcare professionals on new hygiene trends or experi- Centres for Surveillance” (NRZ), Berlin, Germany (www.nrz-hygiene.
ences. Hygiene experts are registered nurses and gained their knowl- de). Each hygiene expert gave oral feedback to healthcare profes-
edge in a postgraduate course (60 ECTS [European Credit Transfer and sionals immediately after a compliance measurement took place.
Accumulation System]) of the Medical University of Graz in order to Additionally, a report template for compliance measurements
detect, prevent and combat infections. Furthermore, hygiene experts was compiled for the management. The report was structured as fol-
follow internal standard operating procedures which were issued to- lows: name of the department/division, date of compliance measure-
gether with experts of the Institute of Microbiology and Hygiene. ment, name of observing hygiene expert, results of compliance rates
In-­house trainings which were performed by hygiene experts for the M5M for HH, results of compliance rates for each healthcare
comprised face-­to-­face instructions (theoretical lecture and prac- professional group (physician, nurse, other) and recommendations to
tical demonstration using UV black light) according to existing improve compliance if compliance rates were below the emphasised
in-­house HH standard operating procedures. In 2013, 1,620 health- level goal of 80%. The report was forwarded to managers in order to
care professionals were educated in 66 in-­house trainings, 1,399 in also raise their awareness concerning the compliance results.
2014 (45 in-­house trainings), 586 in 2015 (26 in-­house trainings),
1,172 in 2016 (40 in-­house trainings) and 1,232 in 2017 (62 in-­
3.4 | Data analysis
house trainings). This amounted to 6,009 of 6,189 (97.1%) full-­time
equivalents (including administrative employees; status 2017) being In the rare occasion that a ward was observed twice in 1 year, the
trained. In such trainings, all healthcare professional groups, includ- compliance rates of both observations were pooled. Compliance
ing students, were obliged to take part. For example, these trainings data were descriptively summarised using means and standard devi-
included topics such as (a) M5M for HH, (b) isolation of patients, (c) ations as well as boxplots. Linear mixed model analyses were used to
hygiene measures in terms of multiresistant germs, (d) good hygiene estimate an overall compliance trend over the years of observation
practice when changing dressings, (e) surgical hand disinfection or as well as profession-­specific and HH-­moment-­specific trends. Due
(f) hygiene standards in an operating theatre. The content of training to repeated measurements, the different wards were used as ran-
was adjusted to the respective ward type and training participants. dom effects. In these analyses, only wards with compliance observa-
Recently, a mandatory e-­learning platform was also introduced tions in at least 2 years were considered. The results are presented
hospital-­wide. All healthcare professionals as well as administrative along with their 95% confidence intervals (CI) and trend plots are
personal were obliged to pass one hygiene unit including general used for visualisation. All analyses were performed using r version
HH-­aspects. All new employees are also obliged to take part in these 3.4.2.
 |
4       HOFFMANN et al.
TA B L E   2   HH compliance rates
HH compliance rates (%)
2013 2014
Overall compliance 81.9 ± 5.2% 83.5 ± 7.5%
Nonsurgical wards 81.9 ± 5.2% 83.6 ± 7.8%
Surgical wards — 82.0%
3.5 | Ethical considerations
The study was approved by the Ethics Committee of the Medical
University of Graz (vote#: 29-­458 ex16/17). Each ward was in-
formed by their managers in advance that an observation would be
performed in the near future. The research and reporting methodol-
ogy followed SQUIRE 2.0 (see Supporting Information Appendix S1).
4 |   R E S U LT S
4.1 | Overall HH compliance rates in wards
From 2013 to 2017, a total of 84 compliance measurements with
19,295 moments for HH took place in 49 wards (moment 1 = 4,807
observations, moment 2 = 2,604 observations, moment 3 = 3,198
observations, moment 4 = 5,022 observations and moment
5 = 3,664 observations). However, in only 32 of the wards, more
than one compliance measurement was performed in these five
years (67 compliance measurements with 15,024 moments for HH
in total).
The overall mean HH compliance increased from 81.9 ± 5.2%
in 2013 to 94.0 ± 3.6% in 2017. In nonsurgical wards (n = 64 ob-
servations), HH compliance increased from 81.9 ± 5.2% in 2013 to
93.5 ± 3.5% in 2017. In surgical wards (n = 20 observations), HH
compliance was 82.0% in 2014 (only one observation) and increased
to 97.8 ± 0.6% in 2017 (see Table 2). The overall baseline estimate
for wards with observations in at least 2 years was 80.6% (95% CI
77.0%–84.2%) in 2013 and the estimated increase per year was 3.4%
(95% CI 2.1%–4.7%, p < 0.001). Nonsurgical wards had a trend of
plus 3.4% (95% CI 2.1%–4.7%, p < 0.001) compliance per year. For
surgical wards, only 14 observations were available, resulting in an
F I G U R E   1   Overall compliance rates per healthcare professional during the observational period per year
2015 2016 2017
87.4 ± 7.4% 88.9 ± 6.8% 94.0 ± 3.6%
88.0 ± 6.6% 91.3 ± 4.5% 93.5 ± 3.5%
86.4 ± 9.5% 84.9 ± 8.3% 97.8 ± 0.6%
estimated increase of 4.2% (95% CI −2.2%–10.6%, p = 0.158) per
year.
4.2 | Healthcare professionals HH compliance rates
Physicians were observed in 4,046 HH opportunities correspond-
ing to 21% of all possible HH moments, nursing staff in 13,347
(69%) and others in 1,902 (10%). Overall, each professional group
was able to increase HH compliance over the study period (see
Figure 1). This also holds for nonsurgical wards: physicians improved
from 69.0 ± 16.6% in 2013 to 89.0 ± 6.7% in 2017, nursing staff
from 86.0 ± 6.9% in 2013 to 96.0 ± 3.2% in 2017, and others from
60.5 ± 27.9% in 2013 to 81.0 ± 20.7% in 2017. Similar results can be
seen for surgical wards: physicians’ compliance improved from 65.5%
in 2014 (only one observation) to 91.5 ± 6.0% in 2017, nursing staff’s
from 89.7 in 2014 to 99.0 ± 0.5% in 2017, and others from 79.2 in
2014 to 100.0 ± 0.0% in 2017. The estimated trend was a 7.8% (95%
CI 4.4%–11.2%, p < 0.001) increase per year from a baseline value of
58.4% in 2013 for physicians, a 2.2% (95% CI 1.1%–3.2%, p < 0.001;
baseline 87.9%) increase per year for nursing staff and a 2.1% (95%
CI −2.1%–6.4%, p = 0.316; baseline 74.2%) increase per year for oth-
ers (see Figure 2).
4.3 | Compliance rates according to the “M5M for
HH”
Overall, HH compliance for each of the M5M for HH increased over
the study period. In nonsurgical wards, HH compliance was between
73.8% (#1)–88.3% (#3) in 2013 and improved between 5.4% (#4)–
20.1% (#2) over the study period. The compliance rate for surgical
wards was between 78.0% (#1)–95.5% (#3) in 2014 and improved
HOFFMANN et al.
F I G U R E   2   Overall estimated trend of
compliance per healthcare professional
between 4.6% (#3)–19.7% (#1) to at least 97% over the study period
(see Figure 3 and Table 3). The estimated overall trend for each of
the M5M for HH is depicted in Figure 4 and was significant for every
moment of HH p ≤ 0.002) (see Figure 4).
5 | D I S CU S S I O N
In general, adherence to HH guidelines is important in terms of pa-
tient safety, and the University Hospital Graz ranked insufficient HH
as a top risk (Korhonen et al., 2015; Sendlhofer, Brunner, et al., 2015;
F I G U R E   3   Overall compliance rates for each of the M5M for HH during the observational period
|
      5
Sendlhofer, Krause, et al., 2015). Therefore, an iterative process was
implemented to improve HH knowledge and consequently HH com-
pliance rates. Assessing the effectiveness of the iterative process
over a period of 5 years showed that training of 6,009 healthcare
professionals and 19,295 observed HH moments resulted in a sig-
nificant increase in HH compliance rates across all healthcare pro-
fessional groups as well as for all M5M for HH. HH compliance of
nurse was already high from the beginning, whereas physicians and
others showed potentials for improvement.
In 2016, first results providing a baseline benchmark on the
German campaign “Aktion Saubere Hände” were reported by
 |
6       HOFFMANN et al.

TA B L E   3   Overall compliance rates according to the M5M for HH

M5M for HH 2013 2014 2015 2016 2017

All ward types

#1 73.8 ± 8.8% 75.4 ± 13.2% 85.1 ± 8.8% 85.7 ± 8.6% 90.7 ± 5.7%
#2 74.1 ± 13.3% 84.4 ± 9.3% 84.1 ± 13.5% 85.5 ± 14.2% 94.6 ± 4.7%
#3 88.3 ± 10.3% 86.1 ± 10.2% 90.4 ± 7.5% 91.4 ± 6.6% 95.9 ± 5.1%
#4 88.0 ± 1.0% 85.4 ± 8.3% 90.3 ± 5.7% 90.3 ± 6.4% 93.9 ± 4.8%
#5 83.1 ± 7.4% 87.7 ± 10.6% 85.4 ± 12.1% 90.6 ± 7.1% 95.8 ± 4.4%
Nonsurgical wards
#1 73.8 ± 8.8% 75.1 ± 13.8% 85.6 ± 8.1% 88.1 ± 6.9% 89.7 ± 5.4%
#2 74.1 ± 13.3% 84.5 ± 9.7% 85.9 ± 10.4% 91.6 ± 9.8% 94.2 ± 4.9%
#3 88.3 ± 10.3% 85.3 ± 10.3% 90.7 ± 5.6% 93.1 ± 6.4% 95.3 ± 5.2%
#4 88.0 ± 1.0% 85.9 ± 8.6% 90.1 ± 5.8% 91.4 ± 4.9% 93.4 ± 4.9%
#5 83.1 ± 7.4% 88.3 ± 10.9% 86.4 ± 11.2% 91.7 ± 6.0% 95.5 ± 4.7%
Surgical wards
#1 — 78% 84.0 ± 10.9% 81.5 ± 9.9% 97.7 ± 2.2%
#2 — 83.3% 80.5 ± 18.9% 75.1 ± 15.0% 97.1 ± 2.6%
#3 — 95.5% 89.6 ± 10.9% 88.5 ± 6.2% 100%
#4 — 80.8% 90.5 ± 6.0% 88.5 ± 8.4% 97.3 ± 2.3%
#5 — 81.0% 83.4 ± 14.7% 88.7 ± 8.8% 97.6 ± 0.4%

F I G U R E   4   Overall estimated trend

of the M5M for HH per healthcare
professional

Wetzker et al. Based on observational data submitted by participat-
ing hospitals of the German campaign, it was shown that the overall
median compliance of 97 participating acute care hospitals with 434
nonsurgical and surgical wards was 72% for a given year (Wetzker
et al., 2016). In 2013, within our hospital, the overall mean HH com-
pliance rate was 10% higher than in German hospitals. The imple-
mented iterative process supported to increase HH compliance rates
above the intended goal of 80% (Aktion Saubere Hände & Charité
Universitätsmedizin Berlin, 2016). In our study, the professional
group of nurses was even able to reach the goal of 90%. Therefore,
a bundle of recurring interventions such as information for all stake-
holders, trainings, immediate feedback, standardised reporting, in-
volvement of the management and compliance measurements on a
regular basis rather than singular individual measures seems to be
needed to change habits and to increase HH compliance rates.
Several studies reported that nurses have higher HH compli-
ance rates than physicians (Chen et al., 2016; Hugonnet et al., 2002;
Wetzker et al., 2016). As this difference was also observed in the
current study, a possible explanation could be that implemented
measures such as trainings and feedback after compliance measure-
ments might have targeted specific healthcare professional groups
disproportionately. Compliance rates were not influenced by the fact
that 69% of all HH moments were observed within the professional
group of nurses, in contrast to only 21% within physicians. However,
this distribution corresponds to the number of employed healthcare
professionals, namely, in 1,227 physicians and 2,868 nurses (full-­time
equivalents, 2017). Furthermore, subjective prioritisation of HH may
also differ across healthcare professional groups. It has been previ-
ously shown that physicians assign less importance to HH in gen-
eral (Wetzker et al., 2016). However, within the current study, it was
HOFFMANN et al.
demonstrated that constant involvement of physicians during compli-
ance measurements, trainings and feedback resulted in a steady and
significant increase of HH compliance rates over the period of five.
In previous studies, the overall rates of HH compliance were
significantly higher after exposure to bodily fluids and after pa-
tient contact (Aktion Saubere Hände Referenzdaten 2016; Wetzker
et al., 2016). This can be explained because these practices serve
self-­protecting purposes against infection. However, the current
study also revealed remarkable improvements for all M5M for HH
over the observational period of 5 years (Aktion Saubere Hände
Referenzdaten 2016; Sendlhofer, Brunner, et al., 2015; Sendlhofer,
Krause, et al., 2015; Wetzker et al., 2016).
The Hawthorne effect, also called observer effect, is assumed
to inflate HH compliance when it is measured by direct observation
(Kowitt, Jefferson, & Mermel 2013; Whitby, McLaws, & Ross 2006).
Nevertheless, repetitive direct observations are needed in order to
change habitual processes of healthcare professionals. If healthcare
professionals indeed perform only better when they are observed,
it is important to perform observations on a regularly basis. Due to
these regular compliance measurements, healthcare professionals
might have a learning curve and try to improve their own behaviour in
the future. Furthermore, it can be assumed that reporting of HH com-
pliance rates to the department managers was also an important man-
agerial tool in order to support awareness of HH compliance results.
The major strength of this HH study was that compliance mea-
surements were performed continuously over a period of 5 years,
resulting in a large number of observed M5M for HH. It was demon-
strated that compliance improvements were not a “one-­hit wonder”
as all healthcare professions improved constantly over the obser-
vational period. The implementation of the information campaign,
continuous trainings, compliance measurements and feedback
mechanism informing observed healthcare professionals as well as
the department managers were a helpful tool to increase awareness
of this important patient safety topic.
6 | LI M ITATI O N S
Limitations of the study include the inability to assess the effective-
ness of individual measures such as trainings, the poster campaign,
congresses or e-­newsletters in increasing HH compliance separately.
Second, the present study did not collect data on HAI and thus did
not allow evaluating any potential effects of improved HH compli-
ance during the observational period. Finally, not each ward was ob-
served in every year, meaning that trend estimates cannot directly
be applied to each ward.
7 | CO N C LU S I O N
The implemented iterative process demonstrated remarkable im-
provements in HH compliance rates. A positive trend was observed
across all healthcare professional groups and for all M5M for HH,
|
      7
which strengthens the hypothesis that an iterative process can be ef-
fective in tackling complex issues such as HH where barriers are more
often reported than facilitators. Nonetheless, the importance of HH
needs to be continuously emphasised. In order to facilitate lifelong
learning, starting in 2018, each healthcare professional as well as each
graduate in our hospital has to pass an e-­learning unit on HH, which
has to be repeated every 2 years. We expect this measure to further
improve HH.
8 | R E LE VA N C E TO C LI N I C A L PR AC TI C E
The study highlights how a key challenge such as behaviours con-
cerning HH habits can be tackled. To raise awareness concerning the
M5M for HH, it needs permanent information, training, observation
such as using the method of compliance measurements and perma-
nent feedback. If healthcare professionals perceive that a topic such
as HH is an important issue of the management and when they know
that observations take place regularly, a change in behaviours can be
achieved.
AC K N OW L E D G E M E N T S
The authors wish to express their gratitude to the entire organisation
for their willingness to support patient safety issues. We also would
like to thank our hygiene experts Kathrin Pepper, Hermine Hörhan,
Cornelia Jeuschnigger, Christine Prietl and Claudia Höfer who per-
formed all compliance measurements as well as trainings together with
our physicians (Klaus Vander, Georg Steindl) of the Hygiene Institute.
C O N FL I C T O F I N T E R E S T
The authors have declared that no competing interests exist.
CONTRIBUTIONS
GS, VG and RZ designed and performed the study. MH, CT, GS and
GB interpreted data and contributed to discussions. GP performed
statistical analysis and GB supervised the project.
ORCID
Gerald Sendlhofer  http://orcid.org/0000-0002-6538-3116
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S U P P O R T I N G I N FO R M AT I O N
Additional supporting information may be found online in the
Supporting Information section at the end of the article.  
How to cite this article: Hoffmann M, Sendlhofer G,
Pregartner G, et al. Interventions to increase hand hygiene
compliance in a tertiary university hospital over a period of
5 years: An iterative process of information, training and
feedback. J Clin Nurs. 2018;00:1–8. https://doi.org/10.1111/
jocn.14703