Hand hygiene compliance among healthcare workers before and after a CFIR-guided role-stratified intervention: a mixed-methods study in a tertiary hospital

Abstract

Introduction: This study aimed to evaluate hand hygiene compliance among healthcare workers of different roles, identify key barriers using the Consolidated Framework for Implementation Research (CFIR), and assess the effectiveness of a CFIR-guided stratified intervention in a tertiary hospital. Methods: An exploratory sequential mixed-methods study was conducted at Beijing Hospital, National Center of Gerontology, from December 2024 to September 2025. The observational phase included 9,767 non-announced direct observation hand hygiene observations and a survey of 275 staff (71 physicians, 173 nurses, 31 support staff), supplemented by 15 semi-structured interviews. A six-month CFIR-guided intervention was then implemented, incorporating role-specific training sessions, data-driven feedback, visual reminders, and position-based supervision tailored to physicians, nurses, and support staff. Outcomes included hand hygiene compliance and correctness, knowledge scores, and hospital-acquired infection (HAI) rates. Results: At baseline, compliance differed by role: nurses 81.6%, physicians 72.6%, and support staff 39.3% (p < 0.001). Knowledge scores were significantly lower among support staff (58.6 ± 9.4) than physicians and nurses (66.1 ± 6.9, p < 0.001). Qualitative interviews and CFIR-based surveys identified barriers including workflow constraints, insufficient supervision, inadequate training coverage, and knowledge gaps. Following the intervention, overall compliance increased from 74.9 to 85.4% (p < 0.001), with the largest improvement among support staff (39.3% vs. 56.0%, p = 0.002). Compliance improved across all "five moments," particularly before patient contact (+18.5%, p < 0.001). HAI rates were lower from 3.05 per 1,000 patient-days to 1.66 per 1,000 patient-days (p = 0.002), with reductions observed in respiratory, urinary tract, bloodstream, and surgical site infections during the study period. Conclusion: Hand hygiene compliance varies substantially across healthcare worker roles, with support staff representing a critical gap. A CFIR-guided, stratified intervention was associated with increases in compliance and correctness, particularly at high-risk moments, and reduced HAI incidence, suggesting its potential value as a sustainable framework for hospital-wide infection prevention.