The effect of behavioural interventions targeting hand hygiene practices among nurses in high-income hospital settings: a systematic review

Abstract

Background Hand hygiene is a critical behaviour for infection control but efforts to raise compliance among clinical professionals have been met with mixed success. The aim of this systematic review was to identify the effectiveness of the behaviour change techniques utilised in recent hand hygiene interventions that seek to improve hand hygiene compliance among nurses in hospitals in high-income countries. Nurses are at the frontline of healthcare delivery, and so improving their HH behaviour and thus increasing HHC rates will have a relatively large impact on reducing transmission and preventing healthcare acquired infections. Methods High-quality studies among nurses in high-income countries were surveyed from the scientific literature, following PRISMA guidelines, to identify which kinds of behaviour change mechanisms have been used to effectively increase hand hygiene compliance. Only seven studies met all inclusion criteria. A formal meta-analysis was not conducted due to the heterogeneity of the included studies. Instead, the review analysed studies in line with the Intervention Component Analysis approach to identify which differences in intervention characteristics appear to be important. Analysis proceeded in two steps: first, the Effective Practice and Organization of Care Data Extraction Checklist was used to identify the study design and to describe the intervention, target population, setting, results, outcome measures, and analytic approach. The second step involved inferring the behavioural change techniques used in the complex study interventions. Following coding, logic models were then inferred for each study to identify the Theory of Change behind each intervention. These Theories of Change were then examined for suggestions as to which BCTs were likely to have been responsible for any effectiveness observed. Results Goals and planning (to achieve specific ends), comparison of behaviour (to peers or some ideal) and feedback and monitoring (observing and providing feedback about behaviour or outcomes) were the most frequently used behaviour change technique groupings used across studies and within interventions. Conclusion The complexity of the interventions used and lack of sufficient studies makes assignment of responsibility for behaviour change to specific behaviour change techniques difficult. Delivery channels and activities identified in the study Theories of Change were also highly individualized and so difficult to compare. However, we identified a temporal shift in types of techniques used in these recent studies on HH interventions, as compared with studies from prior to the review period. These newer interventions did not focus on providing access to alcohol-based hand rub or trying to solely encourage administrative support. Instead, they had nurses create goals and plan how to best facilitate HH, compared both individuals’ and the group’s behaviour to others, and focused on providing feedback.

The behaviours identified and the behaviour change techniques planned in health partnerships for antimicrobial stewardship

“…Feedback on behaviour has previously been shown as a significantly encouraging technique for changing long‐term antibiotic prescribing behaviour (Crayton et al, 2020). Findings from a systematic review of behavioural interventions to changing hand hygiene amongst nurses found that goals and planning, feedback and monitoring, and comparison of behaviour were most commonly used to change behaviour (Sands et al, 2020). Participants could be encouraged to think about their current AMS‐related behaviours and future solutions, we recommend 6.2 social comparison of behaviour , more frequent use of 1.1 goal setting , and techniques to review 1.6 discrepancy between current behaviour and these goals.…”

Teaching health care students hand hygiene theory and skills: a systematic review

“…A recent review examining behavioural interventions to improve hand hygiene has noted a change in emphasis from direct measures such as providing alcohol hand-rub towards more motivational techniques. These include goal setting and planning, comparing individual and group behaviour, and provision of feedback (Sands et al 2020). It may be that newer educational interventions are making a similar move from didactic teaching to a more reflective approach.…”

“…When considering educational interventions it is important to consider cognitive learning, psychomotor, and affective skills (World Health Organization 2009); and to work towards including the higher levels of a taxonomy such as that by Bloom which deal with synthesis and analysis; as well as the lower levels of knowledge, comprehension and application (Adams 2015). However, as with the behavioural change interventions, unpicking and identifying each of these in an individual educational intervention which forms part of a broader educational programme can be challenging (Sands et al 2020). A more reflective approach might also elevate patient safety to the same level as that of personal protection, which may for some be a more compelling force for change (Borg et al 2009).…”

Improving research personnel’s hand hygiene adherence in the pediatric acute care setting during the COVID-19 pandemic: a quality improvement initiative

“…5 Multifaceted behavior change-oriented interventions have effectively promoted hand hygiene compliance and subsequent reduction of nosocomial infection in health care settings. 6,7 Clinical research assistants (RAs) frequently work alongside clinical staff and interact with patients but may be excluded from infection control training programs and may receive no formal instruction on hand hygiene procedures. As a result, existing hand hygiene data audits carried out by health authorities may be inaccurate estimates of true adherence to hand hygiene by all hospital personnel in the patient environment and may not reflect true healthcare-associated infection transmission pediatric emergency department (ED) and subsequently increase group hand hygiene adherence to 80% over 11 months through evidence-based interventions.…”

“…5 Multifaceted behavior change-oriented interventions have effectively promoted hand hygiene compliance and subsequent reduction of nosocomial infection in health care settings. 6,7…”