PSYCHOLOGY, HEALTH & MEDICINE

PSYCHOLOGY, HEALTH & MEDICINE

Explaining hand hygiene practice: an extended application of the Theory of Planned Behaviour

E. A. JENNER,1 P. W. B. WATSON,1 L. MILLER,1 F. JONES1 & G. M. SCOTT2 1University of Hertfordshire, HatŽ eld & 2University College Hospitals, London, UK

Abstract Health care workers’ hand hygiene practice is universally sub-optimal. This contributes to the 8% prevalence rate of hospital-acquired infection which is currently costing the National Health Service in England nearly £1 billion per annum. It is estimated that about 30% of hospital-acquired infections could be prevented if health care workers adhered to hand hygiene guidelines. The aim of the study was to identify psychological constructs predictive of health care workers’ hand hygiene behaviour in order to determine ways to improve practice. We used a cross-sectional survey of 104 hospital-based health care workers. Data were analyzed through hierarchical logistic regression. The model correctly classiŽ ed 79% of cases in intention to perform appropriate hand hygiene and 87% of self-reported hand hygiene behaviour. Attitudes and personal responsibility were signiŽ cant predictors of intention, whilst perceived behavioural control and intention were signiŽ cant predictors of behaviour. The theoretical framework shows where future interventions to improve hand hygiene practice should be targeted. PSYCHOLOGY, HEALTH & MEDICINE

Introduction

Hand hygiene is the single most important behaviour to prevent cross-infection (Black et al., 1981; Conly et al., 1989; Khan, 1982; Mortimer et al., 1966; Semmelweis, 1861; Shahid et al., 1996; Stanton & Clemens, 1987), yet many observational studies have shown that health care workers’ adherence to hand hygiene standards is universally sub-optimal. For example, Tibballs (1996) found that doctors washed their hands on only 8.6% (range 0–33%) of the occasions when it was deemed appropriate. PSYCHOLOGY, HEALTH & MEDICINE

It is not only doctors, however, who have been found to be non-adherent but also nurses (Albert & Condie, 1981; Bartzokas et al., 1994; Gould, 1994; Gould et al., 1996), dentists and dental students (Porter et al., 1995), physiotherapists and radiographers (van de Mortel & Heyman, 1995), respiratory therapists, electrocardiographic and radiographic technicians (Wurtz et al., 1994) and occupational therapists (Marcil, 1993). As Goldmann and Larson (1992) point out, ‘Experts in infection control coax, cajole, threaten and plead, but still their colleagues neglect to wash their hands’ (p. 120). This failing contributes to approximately

Address for correspondence : Elizabeth A. Jenner, Department of Post-Registration Nursing, University of Hertfordshire, College Lane, HatŽ eld, Hertfordshire, AL10 9AB, UK. Tel: 1 44(01707) 284429; Fax: 1 44(01707) 284954; E-mail: e.a.jenner@herts.ac.uk PSYCHOLOGY, HEALTH & MEDICINE

ISSN 1354-8506 print/ISSN 1465-3966 online/02/030311-16 Ó Taylor & Francis Ltd DOI: 10.1080/13548500220139412

312 E. A. JENNER ET AL.

one in every 12 patients acquiring an infection as a direct result of their hospitalization (Emmerson et al., 1996). The cost to the National Health Service is nearly £1 billion pounds per annum (Plowman et al., 1999). However, it is not only the Ž nancial implications that are important but also the physical and psychological costs endured by patients and their families. Whilst the eradication of all hospital-acquired infections is an unrealistic goal, there is a commonly held view that perhaps 30% could be prevented (DOH/PHLS, 1995), leaving what Ayliffe (1986) termed ‘the irreducible minimum’. The Chief Medical OfŽ cer has recently issued guidance on how to tackle the growing problem of hospital care-associated infection (CMO, 2002). Given the relationship between hand washing and the prevention of cross-infection, increasing adherence is one obvious solution. PSYCHOLOGY, HEALTH & MEDICINE

Reasons for non-adherence

Some reasons for health care workers’ non-adherence to hand hygiene guidelines have been identiŽ ed. Various studies have reported that environmental factors can effectively constitute barriers to performing the behaviour, such as harsh hand washing agents (Zimakoff et al., 1992) and paper towels (Heenan, 1992) and inaccessibility or insufŽ cient numbers of sinks (Kaplan & McGuckin, 1986). Another barrier is health care workers’ perceptions about a lack of time to wash their hands. The ideal duration for hand washing is not known and it is worth noting the difference in the lengths of time promulgated by various countries. For example, in the UK, the technique most commonly advocated takes 60 seconds and is based on a test procedure described by Ayliffe et al. (1978). In the USA, however, the guidelines produced by the Centers for Disease Control recommend that this behaviour can be performed in ten seconds (Garner & Favero, 1985). However, despite this quicker technique, health care workers still claim that they do not have time (Larson & Killien, 1982). Time constraints therefore would appear to be an important consideration, and Voss and Widmer (1997) ask whether we can afford 100% compliance. Using a mathematical model, they calculated that in a 14-bed intensive therapy unit, with 12 staff each working eight hours, it would take 16 hours, or two full-time nurse equivalents a day, to achieve 100% compliance with hand washing. Weeks (1999) estimates that by not washing his hands between each of the 60 ‘touch’ contacts he has every day with obstetric patients, he saves on average one or two hours, equivalent to 15% extra stafŽ ng that would be needed to cover the extra time. PSYCHOLOGY, HEALTH & MEDICINE

In an attempt to address health care workers’ perceptions about a lack of time, several types of alcohol-based products have now been marketed, including wipes (Butz et al., 1990) and gel (Newman & Seitz, 1990), in addition to hand rubs (Mackintosh & Hoffman, 1984). These can be applied and rubbed to dryness in Ž ve seconds whilst moving between patients. However, such products should only be used for decontaminating hands that are not visibly soiled, hence hand washing is still indicated under certain circumstances. Voss and Widmer (1997) calculated that in an Intensive therapy unit, if hands were decontaminated with alcohol dispensed from containers on every bedside locker, it would take only four hours per day to achieve 100% compliance. It was to be hoped that the introduction of alcohol-based products would improve adherence, but unfortunately Gould (1994) found this not to be the case. It would appear therefore that ‘the primary problem with hand hygiene is not a paucity of good products, but rather the laxity of practice’ (Larson, 1995 p. 259).

Improving adherence

Numerous studies have been conducted in attempts to improve adherence to hand hygiene. Interventions aimed at addressing environmental barriers include providing an emollient soap PSYCHOLOGY, HEALTH & MEDICINE

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(Kolari et al., 1989; Mayer et al., 1986) and making hand washing easier by, for example, increasing the ratio of sinks to beds (Kaplan & McGuckin, 1986) or introducing automated hand washing machines (Wurtz et al., 1994).

Studies also have been conducted to teach health care workers about the importance of hand washing. Interventions have included the use of educational and feedback strategies (Dubbert et al., 1990; Williams, 1987) and providing cues to action in the form of posters (Lohr et al., 1991). However, while numerous interventions to increase adherence have been designed and implemented, few have been successful in bringing about behavioural change. One possible reason for the failure of educational interventions may be explained by the tendency to assume a relationship between knowledge acquisition and subsequent behaviour change, when in fact this may not be the case. PSYCHOLOGY, HEALTH & MEDICINE

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This misconception has been well illustrated by several researchers. For example, Williams (1987) found that an increase in knowledge about hand hygiene did not translate into improved hand washing practice. Likewise, Alvaran et al. (1994) noted that neither level of knowledge nor positive opinion about the value of hand washing was associated with self-reported increases in hand washing practices. Similar Ž ndings have been reported by Gruber et al. (1989), who compared subjects’ knowledge scores with their scores for implementation of ‘universal precautions’ (a set of infection control practices designed to protect health care workers from contracting blood-borne virus infections through their work). They found that those with higher knowledge in fact had lower practice scores (r 5 2 0.12). Therefore, education alone is unlikely to impact upon hand washing behaviour. Pittet et al. (2000) have recently shown that a combination of strategic interventions is necessary to increase adherence to hand hygiene.

Co-workers can be one source of in uence over an individual’s practice. For example, Jenner et al. (2000) found that exposure to sub-optimal practice had an adverse effect on student nurses’ attitudes to hand hygiene, with attitudes declining signiŽ cantly throughout their three-year training programme. Similarly, Larson et al. (1986) showed that junior doctors may acquire poor hand washing practices from their peers; in contrast Larson and Larson (1983) reported that junior doctors’ hand washing practice improved when a consultant set an example. When attempting to improve adherence, it is clearly important therefore to target consultants who are considered by some to be the worst culprits (Araf et al., 1999) while at the same time are best positioned to act as role models. PSYCHOLOGY, HEALTH & MEDICINE

Another strategy is to enhance an individual’s sense of ownership concerning health- related behaviours and outcomes. This can be thought of in terms of identifying the locus of responsibility for maintaining both one’s own health and the health of others. This has not yet been explored with regard to hand hygiene behaviour, but Rothman et al. (1993) explored the comparative usefulness of ‘internally-orientated’ messages versus ‘externally-ori- entated’ or ‘information-only’ messages to encourage women to attend mammography screening. Internally-oriented messages alone were successful in encouraging attendance. The relevance of this construct to hand hygiene practice would therefore seem worthy of exploration.

The need to explore constructs that are predictive of hand hygiene behaviour has been highlighted by Kretzer and Larson (1998). The primary aim of this study, therefore, was to develop a theoretical framework in order to identify perceived cognitive and physical factors that may explain health care workers’ hand hygiene behaviour. It was postulated that the Ž ndings would provide direction for the design of theoretically driven interventions to improve adherence to hand hygiene guidelines. PSYCHOLOGY, HEALTH & MEDICINE

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Theoretical framework

Theoretical models developed to explain the in uence of beliefs on individuals’ actions include the Health Belief Model (HBM; Rosenstock, 1966), the Theory of Reasoned Action (TRA; Fishbein, 1967) and the Theory of Planned Behaviour (TPB; Ajzen, 1985). The original aim of the HBM was to explain preventative health behaviours. The model consists of Ž ve core constructs, namely perceived susceptibility, perceived severity, costs, beneŽ ts and cues to action. The TRA was developed to explore the relationship between attitudes, subjective norms and intention to perform a behaviour (Fishbein, 1967). The TRA was later expanded by the addition of the construct of perceived behavioural control to form the TPB (Ajzen, 1985). The TPB consists of constructs believed to predict intention to perform behaviour. These are attitudes which can be deŽ ned as the extent to which individuals have a favourable or unfavourable evaluation of the behaviour; subjective norms which refer to the social pressure individuals perceive themselves to be under to perform a behaviour; and perceived behavioural control, which can be deŽ ned as the extent to which individuals believe that they have adequate resources, physical or cognitive, to perform the behaviour. PSYCHOLOGY, HEALTH & MEDICINE

The models described above have been utilized in previous research to examine a wide variety of health behaviours such as exercise (Norman & Smith, 1995) and the uptake of screening for cervical cancer (Hill et al., 1985). They appear to have useful levels of predictive validity in terms of both explaining behaviour and providing information for the construction of theoretically-based interventions. However, to our knowledge, they have not previously been used to examine hand hygiene behaviour.

In this study, the TPB formed the foundation of the theoretical framework. The theory dictates that attitudes, subjective norms and perceived behavioural control are predictive of behavioural intention, while behaviour is predicted by intentions and perceived behavioural control. However, given that the construct of perceived behavioural control would not identify speciŽ c obstacles that may hinder health care workers’ hand hygiene behaviour, the model included the construct of barriers drawn from the HBM (Rosenstock, 1966). These were based on existing literature related to poor hand hygiene adherence: acceptability of hand hygiene agents (Zimakoff et al., 1992), time availability (Larson & Killien, 1982), satisfaction with paper towels (Heenan, 1992) and the number/location of sinks (Kaplan & McGuckin, 1986). It was postulated that these would impact upon intention and behaviour. The model was extended further by the addition of the construct of personal responsibility, which was postulated to be a predictor of intention. The proposed predictive model is shown in Figure 1 PSYCHOLOGY, HEALTH & MEDICINE.