Intensive and Critical Care Nursing 42 (2017) 3–4
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Intensive and Critical Care Nursing
journal homepage: www.elsevier.com/iccn
Editorial
Key factors for hand hygiene promotion in intensive care units
Hand hygiene remains a cornerstone in the fight against
healthcare-associated infections and multidrug resistance (Blot,
2008). Hand hygiene behaviour is deep-rooted and difficult to
change. According to a recently published Intensive & Critical
Care Nursing article by Battistella et al. (2017), professional hand
hygiene behaviour in intensive care settings is influenced by habits
of social handwashing in everyday life. Therefore, they plead for
the creation of specific professional hand hygiene habits (wash-
ing hands should become ‘a routine inside a habit’). In this study,
an action-research approach proved to be a useful methodology to
influence staff and introduce organisational innovations.
Complex and repeatedly organised multi-modal hand hygiene
campaigns are considered the ‘gold standard’ these days. The WHO
introduced its ‘Multimodal Hand Hygiene Improvement Strategy’
in 2009, promoting five essential strategy components: training
and education, system change, evaluation and feedback, reminders
in the workplace and institutional safety climate (WHO, 2009a,b).
Ideally, campaign actions not only focus on the healthcare workers
but also address patients (cf. patient empowerment) and manage-
ment. In its most recent global annual call to action (Save Lives:
clean your hands, 5 May 2017), the WHO specifically targeted hos-
pital management, policy makers and infection prevention control
leaders.
Social cognitive theories, such as the Theory of Planned
Behaviour (TPB) (Ajzen, 1985) or the Attitude Social influ-
ence Self-efficacy model (ASE), help us understand the specific
role of each determinant that can affect behavioural intention
and behaviour (De Vries et al., 1988). Hence, contemporary
state-of-the-art campaigns include actions that affect all, mostly
intrapersonal, behavioural determinants that imply good hand
hygiene behaviour: high knowledge (through education), positive
attitude (through education, discussion and observation), positive
social influence (largely affected by the presence of role mod-
els or hand hygiene ‘compliers’) and high perceived behavioural
control or self-efficacy (through feedback leading to improved
perception of personal abilities). According to Bouadma et al.
(2010), all educational initiatives should therefore be combined
with an associated behavioural strategy. Interpersonal variation
of nurses’ behavioural determinants, behavioural intention and
actual behaviour performance is nearly unlimited. According to
Cole (2009), all hand hygiene campaign actions would therefore be
‘tailored’, targeting poor compliers and reinforcing good compli-
ers. Tailored interventions address the individual characteristics of
http://dx.doi.org/10.1016/j.iccn.2017.06.007
0964-3397/© 2017 Elsevier Ltd. All rights reserved.
healthcare workers (such as personality factors, goals, needs, pref-
erences, and resources) and include training (e.g. psychoeducation
and behavioural/cognitive coping skills training) targeting specific
personality dimensions (Beck et al., 2010).
Education of health care workers in function of a minimum
knowledge basis of hand hygiene seems a first logical and fre-
quently reported initiative for better practice. Recently, a large
international study identified an average low baseline knowl-
edge level regarding healthcare-associated infection prevention
guidelines among 3587 healthcare workers, indicating plenty of
room for improvement (Labeau et al., 2016). Moreover, nurses
should also have sufficient knowledge in order to make a proper
risk assessment in the variety of situations to which they are
exposed (Flores, 2007). Erasmus (2012) showed a strong asso-
ciation between knowledge of hand hygiene guidelines and
self-reported compliance. Subsequently, a specialist education tar-
geting the fit-for-purpose knowledge, skills and expertise in an
intensive care setting could prove worthwhile (Endacott et al.,
2015). Ideally, this specialist education would incorporate a com-
mon knowledge basis of infection prevention and hand hygiene,
derived from a European intensive care nurse curriculum. Unfor-
tunately, most attempts to change behaviour solely by increasing
the knowledge of staff through education or training have failed
(O’Boyle et al., 2001). On the other hand, sufficient knowledge
seems to remain essential as a lack of knowledge will, per defi-
nition, impede adherence (Labeau et al., 2007, 2008). Knowledge
also affects the healthcare workers’ attitude, another key predictor
of behavioural intention. We previously identified that a negative
attitude (in particular towards time-related barriers) and poor self-
efficacy are the most important predictors of noncompliant hand
hygiene behaviour in an ICU (De Wandel et al., 2010). Attitudes can
be very rigid and based on highly irrational beliefs or perceived dis-
advantages. Self-efficacy beliefs and perceived behavioural control,
another important determinant, begin to form in early child-
hood and develop throughout life as people learn, experience and
develop into more complex human beings (Bandura, 1995). Unsur-
prisingly, a low self-efficacy was associated with hand hygiene
noncompliance in previously conducted research (De Wandel et al.,
2010). Self-efficacy can be improved by practice and observational
learning. This leads us to the concept of subjective norms: one’s per-
ception of social pressure (cf. social influence) to perform or not to
perform a behaviour. Social pressure −or social support- is strongly
influenced by the presence of role models or normative referents.
4 Editorial / Intensive and Critical Care Nursing 42 (2017) 3–4
Hand hygiene promotion initiatives should include a methodology
to install a positive social norm. Based on our own ongoing inter-
vention research, we would like to emphasize the added value of
widely-implemented on-floor discussion (moderated group reflec-
tion) in order to tackle poor knowledge (cf. ignorance), attitude (cf.
misconception) and subjective norm.
In this Intensive & Critical Care Nursing issue, two original quali-
tative research articles, both exploratory descriptive studies, on this
subject are published. The study of Sadule-Rios and Aguilera (2017)
aims to identify critical care nurses’ perceptions of barriers to hand
hygiene compliance and their recommendations for improvement.
Forty-seven critical care nurses were asked for 1) their percep-
tions of the reasons for low hand hygiene compliance in the critical
care unit and 2) their suggestions to improve hand hygiene com-
pliance in the critical care unit. High workload, understaffing and
lack of time was reported as the main reason for scoring low-
ranking in hand hygiene compliance, followed by accessibility of
sinks and lack of appropriately located hand sanitizers. According to
the researchers, education and other interventions will not be com-
pletely successful until these issues are addressed. They indicate
the need to implement interventions that target specific barriers
to hand hygiene compliance in the intensive care unit, based on
the reasons for low compliance and suggestions for improvement
the participants expressed (a list of these recommendations for
improvement is included in the article). The researchers conclude
that further studies on the relationship between nurses’ workload,
unit staffing, and hand hygiene compliance are needed.
The study of Piras et al. (2017) aims to describe critical care
nurses’ hand hygiene attitudinal, normative referent, and control
beliefs (or the effect of social influence on critical care nurses’ hand
hygiene adherence). In this elicitation study using the TPB as a
guiding framework, 25 nurses participated. Thematic analysis gen-
erated four themes: ‘hand hygiene is protective’ (nurses responded
the advantage of performing hand hygiene on patient, nurse and
institutional protection level), ‘nurses look to nurses’ (nurse lead-
ers and fellow nurses), ‘time-related concerns’ (as the most widely
reported concern nurses had related to hand hygiene performance)
and ‘convenience is essential’ (indicating the importance of func-
tioning and conveniently located hand hygiene equipment). The
results suggest that hand hygiene attitudinal beliefs are not the sole
moderator of nurses’ hand hygiene performance, as posited by the
TPB. Nurses may perceive social pressure to perform hand hygiene
from unit nurse leaders and fellow nurses. The researchers con-
clude that future research should pay attention to the exploration
of the effects of social influence on nurses’ hand hygiene adherence.
Both studies identified time-related barriers and highlight the
importance of readily accessible supplies. Compared to environ-
mental factors, time-related barriers and workload however are
much more difficult to overcome. Both studies deliver a valuable
contribution to the literature, recognising the importance of ongo-
ing behavioural research in intensive care units.
Conflicts of interest
There are no conflicts of interest to declare.
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David De Wandel a,b
a
Faculty of Education, Health and Social Work,
University College Ghent, Keramiekstraat 80, B9000
Ghent, Belgium
b Faculty of Medicine and Health Sciences, Ghent
University, B900 Ghent, Belgium
E-mail address: david.dewandel@hogent.be
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