Improving Healthcare Worker Hand Hygiene Compliance: The Role of Behavior Change Theories

Abstract

Background. Healthcare worker (HCW) hand hygiene compliance is key to patient safety; however, compliance is suboptimal. Hand hygiene is a complex behavior, yet interventions to improve hand hygiene compliance have often ignored psychological theories of behavior change. This study developed a tool based on psychological theories of behavior change to identify modifiable motivators and barriers for HCW hand hygiene compliance. Methods. Data were collected from a multi-professional sample of HCWs (N = 100) from 10 long-term care facilities in Ontario, Canada, using a cross-sectional, qualitative and quantitative survey study. The survey tool assessed constructs from relevant psychological theories of behavior change, using Likert-scale and openended questions, to examine HCW hand hygiene motivators and barriers. Sociodemographics and self-reported hand hygiene compliance was also measured. Content analysis of the qualitative responses was performed using a codebook based on the Theoretical Domains Framework. Results. Qualitative and quantitative findings were concordant. Key motivators included (1) beliefs about consequences to self, family, or patients, (2) beliefs about social- professional role as a HCW, (3) HCW confidence in ability to perform hand hygiene, (4) social influences and norms, (5) environmental cues, and (6) habitual behavior. Key barriers included (1) resources (time pressure, work load), (2) environmental resources (lack of supplies), (3) attention, memory, and decisional processes (forgetfulness, prioritizing competing demands), and (4) beliefs about negative consequences to self (skin irritation). Knowledge about hand hygiene was not a key motivator or barrier for hand hygiene compliance. Conclusion. Psychological theories of behavior change provide a useful framework for understanding motivators and barriers for HCW hand hygiene compliance. While knowledge is necessary for behavior change, it is not sufficient. We identified several key behavioral constructs that can be targeted when developing novel hand hygiene interventions. This may increase the likelihood of a successful intervention, thereby improving hand hygiene compliance and patient safety and staff health.