Nurses Motivation to Wash Their Hands: A Standardized

Measurement Approach
Carol A. OBoyle, Susan J. Henly, and Laura J. Duckett
Handwashing is a simple procedure that is critical to prevention and control of infections, yet
many health care workers (HCWs) do not practice hand hygiene according to recommended
guidelines. The Handwashing Assessment Inventory (HAI) is a self-report instrument that is
designed to measure the motivational schema of HCWs for handwashing.
Copyright 2001 by W.B. Saunders Company
H
ANDWASHING IS A SIMPLE procedure
that is considered critical for controlling
both nosocomial infections in patients and occupa-
tionally acquired infections in health care workers
(HCWs). Historically, Ignaz Semmelweis, Oliver
Wendell Holmes, Joseph Lister, and Florence
Nightingale were the leaders in developing and
implementing measures for sanitation and hygiene,
such as handwashing, that are now considered es-
sential elements of safe patient care (Cohen, 1984;
Larson, 1989; Gould, 1991). Larson (1988) exam-
ined evidence for a causal link between handwash-
ing and risk of infection and concluded that con-
tinued focus on handwashing as a primary infec-
tion control measure is appropriate.
The handwashing procedure can be mastered
with ease by all levels of HCWs. Appropriate tech-
nique includes the use of soap and water or an
alcohol-based handrub (if hands are not visibly
soiled). When using soap and water, hands should
be placed under running water and, after thorough
distribution of the handwashing soap agent to all
hand surfaces, vigorously rubbed for 10 to 15
seconds. Use of an antimicrobial-containing soap,
detergent, or an alcohol-based antiseptic handrub is
recommended before an invasive procedure is per-
formed or when residual antimicrobial activity or a
reduction in skin ora is desired. According to the
Association for Professionals in Infection Control
and Epidemiology (APIC)s guidelines for hand-
washing and hand antisepsis in health care settings
(1995), HCWs are expected to practice handwash-
ing when hands are visibly soiled, before and after
patient contact, after contact with sources of mi-
croorganisms such as body secretions or excretions
or inanimate objects that are likely to be contam-
inated, and after removing gloves.
Despite the simplicity of the procedure, HCW
adherence to guidelines for handwashing is low.
Reported rates frequently fall below 70%, regard-
less of setting (e.g., long term care, intensive care),
profession (e.g., nurses, physicians), or indication
for handwashing (e.g., before patient care, after
contact with contaminated objects) (OBoyle,
1998). HCWs overestimate their personal adher-
ence to handwashing guidelines (Larson, McGin-
ley, Grove, Leyden, & Talbot, 1986; OBoyle,
1998), with self-reported handwashing rates up to
three times the observed rate (Ronk & Girard,
1994). Activities aimed at increasing HCW adher-
ence to handwashing recommendations have met
with limited success, regardless of whether the
focus was education (Dubbert, Dolce, Richter,
Miller, & Chapman, 1990), feedback about per-
sonal handwashing performance (Mayer, Dubbert,
Miller, Burkett, & Chapman, 1986), or appeals to
reason and logic (Goldrick, LeClair, & Larson,
Carol A. OBoyle, PhD, RN, Clinical Nurse Specialist/Infec-
tion Control, Minnesota Department of Health, Division of
Disease Prevention & Control, Acute Disease Epidemiology
Section, Minneapolis, MN; Susan J. Henly, PhD, RN, Associate
Professor, University of Minnesota School of Nursing, Minne-
apolis, MN; Laura J. Duckett, PhD, RN, Associate Professor,
University of Minnesota School of Nursing, Minneapolis, MN.
Funding for this work was provided by grants from the
Georgetown University School of Nursing, the 3M ENRICH
Program, and the Association of Professionals in Infection
Control Research Foundation.
Address reprint requests to Carol A. OBoyle, PhD, RN,
Clinical Nurse Specialist/Infection Control, Minnesota Depart-
ment of Health, Division of Disease Prevention & Control,
Acute Epidemiology Section, 717 Delaware Street S.E., Minne-
apolis, MN 55440. E-mail: Carol.OBoyle@health.state.mn.us.
Copyright 2001 by W.B. Saunders Company
0897-1897/01/1403-0004$35.00/0
doi:10.1053/apnr.2001.24412
136 Applied Nursing Research, Vol. 14, No. 3 ( August), 2001: pp 136-145
1994; Seto et al., 1990). However, Kelen et al.
(1991) presented compelling data that showed that
a system of immediate feedback in the clinical area
and inclusion of evaluation of adherence to stan-
dard infection control recommendations in annual
reviews resulted in improved adherence to recom-
mended practices.
Handwashing, when it occurs, is performed in
the context of ongoing transaction between the
HCW and the work environment. In clinical set-
tings, the handwashing behavior of HCWs may
reect their assessment of the safety needs of pa-
tients, coworkers, and themselves within the phys-
ical constraints imposed by the environment and
time constraints of their assigned workload. HCWs
report that they are often too busy to wash
their hands (Larson & Killien, 1982; Williams
[OBoyle], Henry, Campbell, & Collier, 1994). At
the same time, prevention of patient infections was
cited as the most important reason for adherence to
handwashing guidelines (Larson & Killien).
HCWs have reported dry, sore hand skin as one of
the negative outcomes associated with handwash-
ing (Larson et al., 1986; Larson, Friedman, Coch-
ran, Treston-Aurand, & Green, 1997). In general,
however, little is known about HCW motivation
for handwashing or the factors that affect their
actual handwashing behavior.
The Handwashing Assessment Inventory (HAI)
was developed to measure the motivational schema
for handwashing among HCWs. The purposes of
this report are to: (a) describe the theoretical and
clinical underpinnings of motivation for hand-
washing, (b) describe the HAI, (c) identify impor-
tant factors in the motivational schema of 120
hospital staff nurses related to handwashing, and
(d) discuss the uses of the HAI in clinical practice
and clinical research.
MOTIVATION FOR HANDWASHING:
THEORETICAL FOUNDATION
The Theory of Planned Behavior (TPB) (Ajzen
& Fishbein, 1980; Ajzen, 1988; Ajzen & Madden,
1986) was proposed to account for motivation to
perform a specic volitional behavior such as
handwashing. Figure 1 outlines the concepts and
relationships in the TPB. The TPB postulates that
the precipitating cause of volitional behavior is
intention to perform the behavior. Intention is pre-
dicted directly by enabling variables: attitude (feel-
ings or affective regard for the behavior), subjec-
tive norm (a persons global perception about
whether people important to him or her think the
behavior should be performed), and perceived be-
havioral control (general perceptions about having
sufcient control to perform the target behavior).
The enabling factors are, in turn, predicted by
beliefs about outcomes of the behavior, normative
beliefs, and control beliefs, respectively. Anteced-
ent conditions such as age, educational achieve-
ment, experience with a specic behavior, and
experimental condition constitute variables that
predispose an individual to perform a particular
behavior.
The TPB has been useful in understanding per-
formance of a wide range of health-related, voli-
Despite the simplicity of the proce-
dure, HCW adherence to guidelines
for handwashing is low.
Little is known about HCW motiva-
tion for handwashing or the factors
that affect their actual handwashing
behavior.
The purposes of this report are to: (a)
describe the theoretical and clinical
underpinnings of motivation for
handwashing, (b) describe the HAI,
(c) identify important factors in the
motivational schema of 120 hospital
staff nurses related to handwashing,
and (d) discuss the uses of the HAI in
clinical practice and clinical re-
search.
NURSES MOTIVATION TO WASH THEIR HANDS 137
tional behaviors (Chan & Fishbein, 1993; Miller,
Wikoff, & Hiatt, 1992; Duckett et al., 1998). The
overall success of the TPB with predicting a wide
range of planned behaviors and elucidating the
processes leading to behavioral performance, as
well as the logical connection with handwashing as
a volitional behavior, led to the use of the motiva-
tional schema of the TPB as the theoretical under-
pinning for the HAI.
CLINICAL ISSUES
Practitioners in clinical settings worked with the
principal investigator (PI) to evaluate the useful-
ness of the TPB for understanding motivation for
handwashing and to suggest clinical issues. Critical
care nurses were interviewed by the PI. For each of
the TPB concepts, open-ended questions related to
handwashing were used to identify content from
the domain of handwashing. Critical care nurses
were asked, what inuences your ability to wash
your hands when you think you should? and,
what are the obstacles to adherence to handwash-
ing in this nursing unit? HAI items reected the
clinical realities as perceived by these nurses. For
example, interviewees indicated that they knew the
indications for handwashing and viewed hand-
washing as a responsibility of nurses; however,
time limitations, crisis situations, and skin damage
were frequently mentioned as obstacles to adher-
ence.
Content from the literature and content identi-
ed by more than one interviewee were used in the
TPB items. The statements, If I regularly follow
the hospitals handwashing protocol . . . my hands
will become dry, cracked and reddened (extremely
unlikely to extremely likely) and I intend to
follow the units handwashing protocol when there
is adequate time (extremely unlikely to extremely
likely) were examples of items that reected
nurses concerns about hand skin and time limita-
tions. Items identied by the clinicians were ar-
ranged into sections of the HAI according to the
variables of the TPB. The content and format of the
HAI were then reviewed for clinical relevance and
ease of reading by focus groups that were com-
posed of critical care nurses and infection control
professionals. The HAI was also reviewed by one
of the creators of the TPB, Icek Aizen,
1
for con-
struct validity (personal communication, June 4,
1996).
HANDWASHING ASSESSMENT INSTRUMENT
The HAI is a self-report instrument that was
designed to measure six aspects of motivation as
described in the TPB, as well as intention to wash
hands and self-assessment of handwashing perfor-
mance. Items are placed in sections of the HAI
according to the concepts of the TPB. The score for
each of the sections was calculated by summing
the individual item scores and dividing by the
number of items answered by each participant;
higher scores were interpreted as reecting a more
positive motivation to wash ones hands. In an
effort to avoid respondent fatigue, prevent the
1
Formerly Ajzen; Dr. Aizen now prefers the spelling
Aizen.
Figure 1. Theory of
planned behavior model.
Modied and reprinted with
permission (Aizen, 2000).
138 OBOYLE, HENLY, AND DUCKETT
problem of participant response sets, and measure
the various ideas suggested by critical care nurses,
items on the instrument are both positively and
negatively worded and keyed (Gregory, 2000).
Negatively scored items (e.g., hands become dry)
were reverse scored before scores for each section
of the HAI were calculated. Higher scores reect a
more positive motivation to wash hands.
The HAI also includes sections in which nurses
complete a self-report assessment of the percent-
age of time they adhere to handwashing recom-
mendations in the clinical setting. The reading
level of the HAI is at the 8th grade, based on the
Flesch-Kincaid Grade Level score, with an ease of
reading score of 62 (most standard documents are
designed to have a score between 60 and 70)
(Flesch Reading Scale, 2000). Consequently, it
takes approximately 10 minutes or less for nurses
to complete the HAI.
A variety of response formats were used for the
HAI scales. A seven-point Likert-type format
was used most frequently (e.g., extremely un-
likely . . . extremely likely). These response op-
tions allow participants to rate estimated likeli-
hoods (for beliefs about outcomes of handwash-
ing), control beliefs, intention to follow the units
handwashing protocol, and strength of beliefs
about expectations of other people important to the
nurse regarding handwashing. Other response op-
tions include a semantic differential scale for the
attitude section of the HAI and an estimation of
percentages (from 0% to 100%) for the self-report
section of personal handwashing practices.
The beliefs about outcomes of handwashing sec-
tion represents cognitive evaluation of the conse-
quences of handwashing. The content of the 14
items addressed transmission of microorganisms
(e.g., protect self, fewer patient infections), com-
fort of the nurse (e.g., remove odors, dry hands),
and professional behavior (e.g., meet patient ex-
pectation; be viewed as a responsible nurse). Re-
spondents used a seven-point scale to rate their
perception of the likelihood with which each out-
come would occur if the procedures for handwash-
ing were followed regularly.
Attitude toward handwashing represents affec-
tive/cognitive evaluation of the handwashing pro-
cedure itself. Semantic differential scales were
used to measure each attitude toward handwash-
ing. Respondents marked their thoughts (e.g.,
necessary/optional, harmful/benecial) and feel-
ings (frustrating/nonfrustrating, soothing/irritating)
on a one to seven point scale.
The normative beliefs scale is a measure of a
nurses perceptions about expectations that specic
other people hold for the nurses personal hand-
washing behavior. The literature and focus groups
identied head nurse, other nurses, patient fami-
lies, patients, coworkers, friends, and physicians as
referents whose expectations might be important to
the nurses performance of handwashing. The
nurses perception of the strength of each referents
expectation for handwashing was marked on a
seven-point scale.
Subjective norm is an overall evaluation by a par-
ticipant of the extent to which important people in his
or her life are thought to support or endorse handwash-
ing. Subjective norm was measured by a single item:
Most people who are important to me think I should
follow the hospitals handwashing protocol.
The control beliefs scale measures the extent to
which a nurse believes that he or she possesses or
has access to resources required to adhere to hand-
washing recommendations in a variety of patient
care situations. Aspects of control included per-
sonal knowledge about the handwashing protocol
(e.g., condent of knowledge), characteristics of
the specic patient assignment (e.g., during an
emergency), and the nursing unit context for the
patient assignment (e.g., during a busy shift).
Perceived control is the overall evaluation of the
control beliefs and measures the degree to which a
nurse believes she or he can implement handwash-
ing practices as recommended. The two perceived
control items reected a direct evaluation of how
much control the HCW thought she or he had over
handwashing and the degree of determination to
adhere to the handwashing protocol.
The HAI is a self-report instrument
that was designed to measure six as-
pects of motivation as described in the
TPB, as well as intention to wash
hands and self-assessment of hand-
washing performance.
NURSES MOTIVATION TO WASH THEIR HANDS 139
Intention in the TPB represents the immediate
antecedent to behavior and is the result of the
nurses attitude toward a behavior and his or her
perception of social pressure to perform the behav-
ior. In the HAI, intention to handwash was mea-
sured by the strength of the nurses plan to adhere
to handwashing recommendations in a variety of
clinical situations. Specic situations identied in
the ve items included infected patients, inade-
quate time, sore hands, and a patient crisis. Re-
spondents also evaluated their intention to wash
hands in all indicated situations.
Self-reported handwashing is an estimate of
handwashing performance in seven specic patient
situations that correspond to APIC recommenda-
tions (1995): before beginning care; when care is
interrupted; between patients; before invasive pro-
cedures; when moving from a contaminated pro-
cedure to a clean one; after removing gloves; and
before touching the nurses own face, nose, or
eyes. Respondents were asked to estimate the per-
centage of time (from 0% to 100%) they washed
their hands in each situation.
STAFF NURSE: MOTIVATIONAL SCHEMA FOR
HANDWASHING METHODS
Setting
Four community nonprot hospitals in a mid-
western metropolitan area with a population of
approximately two million served as study sites.
Hospital size varied from 200 to 900 beds.
Procedure Sample Selection and Procedures
Staff registered and charge nurses eligible for
participation in the study were employed in critical
care or step-down units for at least six months,
worked at least 20% of full-time employment sta-
tus (8 hours/week), and provided direct patient
care. After making arrangements with the nurse
managers of the critical care and step-down units
and with infection control managers, arrangements
were made for the PI to present information about
the study to nurses at times and locations suggested
by the nurse manager. Nurses were recruited at
staff meetings, shift reports, and individual meet-
ings with the PI. The PI presented information
about the nature of the study, the relationship to
nursing practice, and the potential participants role
in the study. Participants were asked to complete
the HAI and allow their handwashing behavior to
be observed for up to two hours.
Nurses who wished to participate signed a con-
sent form, completed the HAI, returned materials
to the PI in a stamped, self-addressed envelope,
and allowed their handwashing behavior to be ob-
served for up to two hours. Procedures for the
study were reviewed and approved by the Univer-
sity of Minnesota and participating hospital insti-
tutional review boards.
Sample
The ndings reported here are based on re-
sponses of 120 registered nurses. Of these, 20
nurses participated in the pilot phase of the study
that allowed preliminary review of instrumentation
and procedures. The remaining 100 nurses partic-
ipated during the study phase of the project only.
Data from all 120 nurses were combined for the
analyses reported here.
FINDINGS
Table 1 contains data regarding motivation for
handwashing among critical care nurses based on
responses to the HAI. Both item and scale infor-
mation are listed. Item means can be compared in
order to determine rated importance of specic
content within each TPB concept. Corrected item
total correlations reect the relationship between
each individual item and the whole scale and item
discrimination, i.e., which items are best at differ-
entiating high and low scores on the scale. Higher
positive correlations indicate greater item discrim-
ination, whereas internal consistency reliability (al-
pha) coefcients reect joint functioning of all the
items in a scale. Although it is possible for alpha
correlations to be negative, they usually range from
low positive to high positive numbers less than
1.00. Alphas in the .80s and .90s indicate a scale
with high internal consistency (Gregory, 2000).
Beliefs About Outcomes
The possible outcome protection of self
earned the highest mean likelihood rating, whereas
good annual evaluation was the lowest ranked
mean rating item. Other handwashing outcomes
rated likely to occur were fewer infections in pa-
tients and meeting expectations of patients and
nurses families regarding handwashing. An esti-
mate of internal consistency reliability was not
computed for these items because they were in-
tended to measure diverse handwashing outcomes
rather than a single underlying construct. However,
140 OBOYLE, HENLY, AND DUCKETT
Table 1. HAI Scales: Item Analyses
Scale
HAI Scales Item Information
M SD Reliability Item Scoring
a
M SD r
b
Beliefs about outcomes 5.17 0.52 n/a Protect self pos 6.05 0.93 0.45
Inuence HCWs pos 5.98 0.94 0.10
Fewer patient infections pos 5.98 0.94 0.13
Protect family pos 5.97 0.93 0.42
Patient expectations pos 5.86 1.14 0.37
Remove odors pos 5.76 1.26 0.16
Sense of satisfaction pos 5.76 1.10 0.36
Be a responsible nurse pos 5.74 1.20 0.32
Protect self from resistant
microorganisms
pos 5.74 1.15 0.38
Damage rings neg 5.66 1.52 0.05
Hands become dry neg 5.18 1.58 0.27
Not enough time neg 5.03 1.76 0.02
Damage ngernails neg 4.97 1.83 0.18
Annual evaluation pos 2.86 1.74 0.15
Attitude 5.69 0.95 0.91 Necessary/optional neg 6.63 0.90 0.46
Foolish/wise pos 6.40 1.21 0.46
Harmful/benecial pos 6.34 1.06 0.55
Practical/impractical neg 5.72 1.53 0.70
Reassuring/troubling neg 5.50 1.51 0.70
Frustrating/non-frustrating pos 5.44 1.53 0.64
Convenient/inconvenient neg 5.12 1.63 0.61
Soothing/irritating neg 4.32 1.56 0.41
Referent beliefs 6.3 0.7 0.89 Head nurse pos 6.94 0.57 0.51
Nurse pos 6.48 0.85 0.73
Patients family pos 6.28 1.00 0.68
Patients pos 6.26 0.99 0.70
Coworker pos 6.18 0.92 0.78
Friends pos 6.08 0.99 0.82
Physician pos 6.00 1.11 0.67
Subjective norm 6.28 0.96 n/a People important to me pos 6.28 0.96 n/a
Control beliefs 5.53 1.1 0.85 Condent of my knowledge pos 5.97 1.18 0.22
When there is adequate time pos 5.89 1.31 0.76
During a busy shift pos 5.76 1.32 0.78
Regardless of assignment pos 5.48 1.41 0.87
During an emergency pos 4.66 1.60 0.68
Perceived control 6.08 0.99 0.64 Believe I can handwash pos 6.09 1.14 0.47
Control over handwashing pos 6.06 1.18 0.47
Intention 5.93 0.76 0.74 When patient is infected pos 6.70 0.63 0.41
When there is adequate time pos 6.48 0.75 0.43
In all situations pos 6.14 1.13 0.67
When my hands are sore pos 5.85 1.11 0.60
In a patient crisis pos 4.47 1.57 0.53
Self-reported
handwashing
c
81.69 15.67 0.87 After direct contact with body
substances
pos 93.19 15.62 0.58
Between patients pos 85.29 17.98 0.71
After removing gloves pos 85.13 19.69 0.61
Before invasive procedures pos 83.70 22.31 0.70
Before touching own eyes,
mouth, nose
pos 78.29 20.81 0.55
Before care pos 75.25 23.48 0.73
Before resuming interrupted
care
pos 70.41 24.76 0.74
Abbreviations: pos, positive; neg, negative.
Note: N 120 except for self-reported handwashing (N 117).
a
Possible range of scores for motivational scales is 1 to 7 (except for self-reported handwashing).
b
The corrected item-total correlation.
c
Possible range of scores: 0% to 100%.
NURSES MOTIVATION TO WASH THEIR HANDS 141
items related to protection of self and family
showed the highest corrected item-total score cor-
relations (approximately 0.40).
Attitude
Based on item mean scores, nurses viewed hand-
washing as necessary, wise, and benecial. After the
negatively keyed items, inconvenience and skin irrita-
tion, were reverse scored, they were rated lowest on
the seven-point scale (approximately 4 to 5). The reli-
ability estimate (alpha) of 0.83 indicates that the atti-
tude items were internally consistent. Corrected item-
total correlations were high, ranging from0.41 to 0.70.
Based on the corrected item-total correlations,
the practical/impractical and troubling/reassuring
items showed the best discrimination, i.e., responses to
these items were best at differentiating high and low
scores on the scale.
Referent Beliefs
The referent to receive the highest score for
expectations regarding adherence to handwashing
recommendations was the head nurse. A physi-
cian I respect received the lowest mean score. The
reliability estimate was high (Cronbachs alpha
0.89), which suggests an internally consistent
scale. Corrected item-total correlations ranged
from 0.51 to 0.82.
Subjective Norm
The single item that measured subjective norm
received high ratings on the seven-point scale
(M 6.28). Nevertheless, variability in responses
was apparent (SD 0.96).
Control Beliefs
The highest overall scores were for condence in
knowledge about handwashing and being able to wash
hands when there is adequate time. The lowest scor-
ing itemfor all study participants was for handwashing
during an emergency. Cronbachs alpha was adequate
(0.85). The corrected item-total correlation for con-
dent of my knowledge (the item with the highest
mean rating), was low (r 0.22). Other corrected
item-total correlations were all high (r 0.76); all of
these items addressed situational constraints on ability
to wash hands.
Perceived Control
The two items that measured perceived control had
similar mean scores that were relatively high ( ap-
proximately 6.00 on the seven-point scale). The vari-
ability of both items was also similar (SD was about
1.1). The estimate of the internal consistency reliability
for the two-item scale was adequate for a newly de-
veloped and very short scale (0.64).
Intention
Of the ve patient situations presented, partici-
pants gave the highest handwashing intention score
to those situations in which the patient had an
infection and the two lowest scores to those situa-
tions in which the nurse had sore hands or in which
a patient crisis situation occurred. Cronbachs al-
pha for the ve-item scale was 0.74. Corrected
item-total correlations were all greater than 0.40;
the all situations item showed the greatest asso-
ciation with the total score.
Self-Reported Handwashing
Nurses reported having washed their hands most
often after direct contact with body substances.
The lowest reported mean score was for handwash-
The possible outcome protection of
self earned the highest mean likeli-
hood rating, whereas good annual
evaluation was the lowest ranked
mean rating item.
The highest overall scores were for
condence in knowledge about hand-
washing and being able to wash
hands when there is adequate time.
Nurses reported having washed their
hands most often after direct contact
with body substances.
142 OBOYLE, HENLY, AND DUCKETT
ing in those patient situations when care was
interrupted.
Criterion-Related Validity
Criterion-related validity refers to the degree to
which an instrument is predictive of theoretically
justied, external behaviors. The correlation coef-
cient is generally used to index criterion-related
validity (Polit & Hungler, 1999). Table 2 lists cor-
relations between the six TPB-based motivational
concepts and two outcomes: intention to wash
hands and self-reported handwashing.
Motivational factors were more related to inten-
tion than to self-reported handwashing. Control
belief and perceived control scores were most re-
lated to both intention and self-report. Referent
belief scores were somewhat associated with inten-
tion but not to self-report.
DISCUSSION
The HAI, grounded simultaneously in the theory
of planned behavior and the practice context for
patient care, is a systematic method for measuring
internal values, feelings, and beliefs of nurses in
regard to handwashing. Findings from the critical
care nurse responses yielded insights into the clin-
ical phenomenon of handwashing and suggested
avenues for further validation of the instrument.
Clinical Practice
Based on mean item responses, safety was an
important motivator of handwashing. Fewer pa-
tient infections and protection of self from seri-
ous infections were regarded as the two most
likely outcomes of handwashing. Both of these
possible outcomes are appropriate concerns, given
frequent clinical events that involve bloodborne
pathogens and antibiotic-resistant organisms. The
ndings corroborate a previous report by Larson
and Killien (1982). Although focus group partici-
pants discussed the sense of obligation regarding
handwashing and protection of the patient, they did
not discuss protection of self, even though it is both
a logical concern and had been previously re-
ported.
In this study, concern about the impact of re-
ceiving a poor job evaluation as an outcome of
failing to wash hands as recommended received
the second lowest average score among the 14
possible outcomes that were rated. Adherence to
handwashing guidelines may not have been in-
cluded in performance reviews at all study hospi-
tals and units; if it was, however, it is possible that
there were no consequences or that nurses were not
inuenced by any of the potential consequences.
HCWconcerns about hand skin health and dry, sore
hands have been identied as an actual handwashing
deterrent (Larson et al., 1997; Larson et al., 1986).
Based on the average item response of 4.32 on the
seven-point scale, nurses in this study regarded hand-
washing as neither soothing nor irritating; however, the
item was the lowest rated of all eight attitude items.
Initially, the low rating was interpreted as evidence of
a negative attitude that might be associated with lower
performance of handwashing. Data that reported an
association between rigorous adherence to handwash-
ing and damaged hand skin (Larson et al., 1997; Lar-
son et al., 1986) suggested an alternate interpretation;
namely, expressed concerns and symptoms of dam-
aged skin may be evidence of positive attitudes toward
and rigorous adherence to handwashing for some
nurses.
The head nurse in acute care patient units has tra-
ditionally represented and articulated management ex-
Based on mean item responses, safety
was an important motivator of hand-
washing. Fewer patient infections
and protection of self from serious
infections were regarded as the two
most likely outcomes of handwash-
ing.
Table 2. Correlations: Motivation Variables,
Intention, and Self-Reported Handwashing
Motivational Factor Intention Self-Report
Beliefs about outcomes 0.38
a
0.27
a
Attitudes 0.46
a
0.31
a
Referent beliefs 0.37
a
0.10 (not signicant)
Subjective norm 0.38
a
0.19
b
Control beliefs 0.72
a
0.41
a
Perceived control 0.60
a
0.31
a
N 120.
a
Correlations signicant at p .01.
b
Correlations signicant at p .05.
NURSES MOTIVATION TO WASH THEIR HANDS 143
pectations and support (or lack thereof) for recom-
mended nursing practices. More recently, the head
nurse or nurse manager role has expanded to include
multiple activities that may occur away from patient
care units and limit daily contact with nursing staff. In
spite of these changes, the high ratings for head nurse
expectations on the referent beliefs scale suggested the
head nurse is perceived as representing the expecta-
tions that nursing practice should occur according to
recommended guidelines.
HCWs assert that they are more likely to adhere
to infection control recommendations when they
perceive the patient has an infection (Larson &
Killien, 1982; Williams [OBoyle] et al., 1994).
Thus, it was not surprising that scores for intention
to wash hands were highest when patients were
known to have an infection.
Larson (1982) and Williams [OBoyle] et al. (1994)
both found that lack of time to adhere to infection
control recommendations was a frequently expressed
concern of HCWs. Here, intention to wash hands was
lowest for the patient crisis situation. Inadequate time
to adhere to infection control recommendations may
reect the nurses awareness of a hierarchy of patient
needs and the nurses perception of the realities of
clinical practice. Insufcient time and competing pa-
tient needs may also have been factors in the lowscore
for the item related to emergency patient situations.
Lack of time and presence of competing demands help
to explain the motivation process by which lapses in
handwashing occur and may be critical to constructing
interventions for improved adherence to recommenda-
tions.
The set of control beliefs items represents the
nurses evaluation of the availability of requisite
resources (internal and external) required to adhere
to handwashing recommendations. Patient situa-
tions described in the HAI items that measured the
sense of control that were more complex and re-
quired simultaneous completion of multiple tasks
(e.g., busy shift, emergencies) were rated lower by
the nurses than other items. These lower ratings
indicate that some nurses in the sample felt less
control over their own handwashing adherence in
these types of situations than in the other situations
on the scale. Control scores were also most related
to nurses intention to adhere to handwashing rec-
ommendations and their self-reported handwash-
ing practices.
Clinical Research
Social Desirability
The critical care nurses focus group addressed
handwashing as an ethical component of patient
care. Handwashing was regarded in positive terms
as an obligation to their patients, but nurses in the
focus group also acknowledged that recommended
handwashing practices were less likely to occur
when the clinical setting was busy.
High scores on the HAI scales may reect par-
ticipant interest in providing socially desirable an-
swers congruent with statements made in focus
groups that handwashing was a desirable, ethical
practice for nurses. There is a tendency to over-
report behavior that is deemed socially desirable
and under-report socially undesirable behavior
(Ajzen, 1988).
Ongoing evaluation of the HAI should include
an evaluation of social desirability. A different re-
sponse format might result in more sensitive mea-
surement on the high end of the scale. The Likert-
type response options may have enabled nurses to
agree with positive statements about the goodness
of handwashing. Paired comparisons, whereby a
respondent was forced to select between hand-
washing and some other action in a complex pa-
tient situation (when handwashing is mandated by
standards) would be one possibility for a future
alternate form of the HAI.
Validation Issues
Items that represent the entire domain of the
motivational schema for handwashing by HCWs
were developed by simultaneous consideration of
the TPB and clinical phenomenon of handwashing
in interviews with professionals and review by
experts and focus groups (as described earlier) to
enhance content validity. The HAI scales were
correlated signicantly with intention and self-re-
ported handwashing among 120 critical care
nurses, which provides support for criterion-related
validity of the scales. Additional validation studies
will be necessary to further evaluate the usefulness
of the TPB as a framework for understanding
nurses motivation for handwashing.
SUMMARY
Handwashing is a fundamental clinical action that
protects patients and HCWs alike from avoidable in-
144 OBOYLE, HENLY, AND DUCKETT
fections in the practice environment. Yet, adherence to
recommendations for this simple procedure is low.
Until now, little has been known about the motivation
for handwashing or the factors that affect actual hand-
washing behavior. The HAI permits this assessment.
Data reported here show that the HAI measured the
internal motivational schema of nurses for handwash-
ing in a valid, reliable, and practical manner. The
impact of social desirability on responses to the current
form of the test should be studied. Additional research
is also needed to study the inuence of clinical work-
loads that frustrate or overwhelm the intentions of
nurses who are motivated to adhere to recommended
practices.
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NURSES MOTIVATION TO WASH THEIR HANDS 145