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doi: 10.4037/ajcc20108922010;19:230-239Am J Crit CareDavid De Wandel, Lea Maes, Sonia Labeau, Carine Vereecken and Stijn BlotUnitsBehavioral Determinants of Hand Hygiene Compliance in Intensive Care

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By David De Wandel, RN, MSc, Lea Maes, PhD, Sonia Labeau, RN, MNSc, CarineVereecken, PhD, and Stijn Blot, PhD

Background Although hand hygiene is the most effective

measure for preventing cross-infection, overall compliance is

poor among health care workers.

Objectives To identify and describe predictors and determi-

nants of noncompliance with hand hygiene prescriptions in

intensive care unit nurses by means of a questionnaire.Methods A questionnaire based on a behavioral theory model

was filled out by 148 nurses working on a 40-bed intensive

care unit in a university hospital. Subjects were asked to fill

out the 56-item questionnaire twice within a 2- to 6-week

period. During this period, no interventions to enforce hand

hygiene occurred on the unit.

Results Response rate for the test was 73% (108/148); response

rate for the retest was 53% (57/108). The mean self-reported

compliance rate was 84%. Factor analysis revealed 8 elemen-

tary factors potentially associated with compliance. Internal

consistency of the scales was acceptable. Intraclass correla-

tion was low (0.60) for

6 subscales. A low self-efficacy was independently associated

with noncompliance (= .379; P= .001). After exclusion of this

variable, a negative attitude toward time-related barriers was

associated with noncompliance (= -.147; P< .001).

Conclusions Neither having good theoretical knowledge of

hand hygiene guidelines nor social influence or moral per-

ceptions had any predictive value relative to hand hygiene

practice. A valid questionnaire to identify predictors and

determinants of noncompliance with hand hygiene has been

designed. Nurses reporting a poor self-efficacy or a poor atti-

tude toward time-related barriers appear to be less compliant.

(American Journal of Critical Care. 2010;19:230-240)

BEHAVIORALDETERMINANTS OF HANDHYGIENE COMPLIANCE ININTENSIVE CARE UNITS

C E 1.0 Hour

Notice to CE enrollees:A closed-book, multiple-choice examinationfollowing this article tests your understanding ofthe following objectives:

1. Recognize the impact of behavioral determi-nants on compliance with hand hygiene rec-ommendations.

2. Describe determinants of noncompliancewith hand hygiene prescriptions among

nurses in a general intensive care unit.3. Understand how a low self-efficacy and a

negative attitude toward time-related barriersare predictors of poor compliance with handhygiene recommendations.

To read this article and take the CE test online,visit www.ajcconline.org and click CE Articlesin This Issue. No CE test fee for AACN members.

230 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2010, Volume 19, No. 3 www.ajcconline.org

2010 American Association of Critical-Care Nurses

doi: 10.4037/ajcc2010892

Patient Safety Issues

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In accordance with the attitudesocial influence

self-efficacy model,12which combines Fishbein and

Ajzens theory of reasoned action13 and Banduras

social learning theory,14 attitude, social influence,

and self-efficacy are valid concepts in predicting onesintention to change ones behavior or even ones

actual change in behavior.15,16

Attitude is primordially based on earlier experi-

ences: behavior that has led to success will be rein-

forced and vice versa. Although ones general attitude

toward a certain behavior is often the result of suc-

cess and failure (or perceived advantage and disad-

vantage), not all attitudes are based on reason and

logical sense. Some attitudes can be very rigid and

based on highly irrational beliefs.

A compliment by a colleague or staff member

as a reaction on adequate hand hygiene practicewould be an example of social support on the inten-

sive care unit (ICU). Although less interactive, being

among high-compliance colleagues (ie, role models)

is also a common example of a positive and valuable

social influence.

Self-efficacy indicates ones belief in ones ability

to behave as desired and to overcome certain barriers.

In other words, self-efficacy is a persons belief in

his or her ability to succeed in a particular situation.

Bandura17 described these beliefs asdeterminants of how people think,

behave, and feel. Behavior that proves

to be less successful or unsuccessful

will be attributed to certain causes.

Such attributions negatively influence

self-efficacy.

The first objective of this study

was to develop and validate a ques-

tionnaire by which determinants of

noncompliance with hand hygiene

can be identified in ICU nurses. The

second objective was to identify andanalyze determinants of noncompliance with hand

hygiene prescriptions among nurses in a general ICU.

MethodsQuestionnaire Development

Based on the literature, a questionnaire about

hand hygiene was developed, including a self-reported

compliance scale (12 items, based on the guidelines

from the Centers for Disease Control and Prevention

[CDC]18) and questions about attitudes toward hand

hygiene (12 items), social influence (10 items),

self-efficacy (10 items), and knowledge about handhygiene (12 items).

Knowledge.The items on the knowledge scale

were selected from a validated CDC questionnaire

on hand hygiene.18The remaining items were con-

structed on the basis of the literature. For each item,

the respondent had to select 1 response from 4 alter-

natives. All 12 items were reviewed by an expert

panel (n= 8) that consisted of 1 microbiologist, 2

infectiologists, 3 infection control nurses, 1 inten-

sivist, and 1 researcher. As a result, some of the

A

lthough hand hygiene is the most effective measure to prevent cross-infection

and as such limits the deleterious effect of health careassociated infection,1-4

overall compliance is unacceptably poor among health care workers. Barriers to

appropriate hand hygiene practice have been studied and reported extensively,

but even in settings with optimal environmental conditions, compliance appears

to range from 50% to 60% at most.1,5-9 Furthermore, few interventions seem to result in a last-ing effect.1,5,7,10These findings suggest that behavioral determinants such as attitude, social

influence, and self-efficacy may play a crucial role in compliance. A recent study by Whitby et al 11

underlines the importance of understanding the dynamics of behavioral change in order to

design a strategy to improve hand hygiene compliance.

About the AuthorsDavid De Wandel and Sonia Labeau are doctoral studentsin the Faculty of Health Care at University College Ghentand Ghent University Faculty of Medicine and HealthSciences, Ghent, Belgium. Lea Maes is a professor in

the Department of Public Health, Faculty of Medicineand Health Sciences, Ghent University. Carine Vereecken isa research collaborator in the Department of Public Health,Faculty of Medicine and Health Sciences, Ghent Univer-sity and for Research Foundation Flanders. Stijn Blot isa research professor in the Department of General Inter-nal Medicine and Infectious Diseases, Ghent UniversityHospital and in the Faculty of Medicine and Health Sci-ences at Ghent University.

Corresponding author: David De Wandel, UniversityCollege Ghent, Faculty of Health Care, Ghent University,Faculty of Medicine and Health Sciences, Keramiekstraat80, B-9000 Ghent, Belgium (e-mail: [email protected]).

www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2010, Volume 19, No. 3 231

Even in settingswith optimalconditions forhand hygiene,complianceranges from50% to 60%.

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inate between high scorers and low scorers. The

following formula was used to divide respondents

into high scorers and low scorers,19with 40% of

respondents in each group: (number of correct

answers in the high-scorer group number of cor-

rect answers in the low-scorer group)/total num-

ber of correct answers in both groups. Items withvalues of 0.35 and higher are discriminating (very)

good, values from 0.25 to 0.35 are satisfying/good,

values from 0.15 to 0.25 are mediocre/satisfying,

and items with values less than 0.15 are bad/medi-

ocre for discriminating between high scorers and

low scorers.20-23

Setting

The study was performed in the 40-bed ICU of

the 1060-bed Ghent University Hospital, a tertiary

care referral center.

Procedure

The questionnaires reliability was assessed by

means of the test-retest method. For test purposes,

the questionnaire was distributed (test) in April 2004

within a time lapse of 2 weeks (T0 to T+2). It was

redistributed for retest purposes within a comparable

period (T+4 to T+6). At T+8weeks, all questionnaires

were collected. The study was approved by the insti-

tutional review board at Ghent University.

Statistical Analysis

Statistical analyses were performed by using

SPSS version 12.0 (SPSS Inc, Chicago, Illinois).

The items with the most severely skewed distribu-

tion (>97%) were discarded because they are not

likely to be useful for a study on determinants. For

the remaining items, factor analyses with varimax

orthogonal rotation were conducted (data not

shown). As the expert panel found 3 attitude items

and 3 social influence items of rather poor quality,

those items were deleted during the questionnaires

development and validation process. The internal

reliability of each factor was tested by using Cron-

bach . The test-retest reliability of the scales was

assessed with the intraclass correlation coefficient.Systematic differences were investigated with a

paired-samples ttest. To investigate the predictive

validity, Pearson correlations were calculated

between the psychosocial constructs and the self-

reported compliance. Finally, a multiple linear

regression was performed with the self-reported

compliance as the dependent variable and the

behavioral constructs as the independent variables.

All 10 variables were included by using the step-

wise selection method.

items were slightly reworded. This method con-

tributed to the content validity. In order to obtain

an average difficulty level, all 12 items were given a

difficulty label by the experts before the question-

naire was distributed. Levels ranged from easy to

quite difficult to difficult.

For each correct response, the respondentreceived 1 point. The sum resulted in the respondents

knowledge score on a scale from 0 to 12 (12 items).

Attitude, Social Influence, and Self-efficacy.The

12-item attitude scale included (1) questions on

specific advantages and disadvantages associated

with desired or undesired behavior

and (2) questions to determine the

respondents general attitude toward

recommended hand hygiene practice.

Ten items were intended to

define the social influence as experi-

enced by the nurses and to provideus with an answer to the following

questions: What is the ruling social norm? What is

the frequency and importance of a role models

presence? To what extent and in what ways are

social support and social pressure experienced by

the nurse?

Ten items were used to determine the nurses

self-efficacy. These questions were intended to

determine crucial barriers that lead to improper

hand hygiene behavior.

All items were to be scored on a 5-point scale,

going from 1 (I completely disagree) to 5 (I com-

pletely agree). Items were constructed on the basis

of information gathered from our literature study.

Hand Hygiene Compliance. Compliance was to

be self-reported on a 5-point numeric scale, ranging

from 0% to 100% in steps of 25%. In

order to include most situations in

which hand washing or disinfection

is recommended, we used an inven-

tory as suggested by the Association

for Professionals in Infection Control

/CDC17 that contains 12 different

opportunities in which hand hygiene

is strongly recommended.Integrity of the Knowledge Test.

In order to determine the integrity of

the knowledge test, its difficulty index and its dis-

crimination index were calculated. The difficulty

index (pi, poptimal in case of 4 answering possibilities

=0.63, pi ranging from 0.30 to 0.70) indicates the

proportion of correct answers on a scale from 0.00

to 1.00.19

The discrimination index (d) indicates the

extent to which items on the questionnaire discrim-

Knowledge ofhand hygiene

guidelines did not

predict their use.


Nurses with poorself-efficacy or anegative attitude

toward time

barriers are lesscompliant.

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ResultsResponse Rates and Population Surveyed

Response rate for the test was 73% (108/148).

Response rate of the retest was 53% (57/108).

Fifty-seven nurses (39% or 57/148) returned both

questionnaires.

The study population was 72% female (n = 78)and 27% male (n= 29). Data were not available for

1 participant. The number of years of

working experience varied from less

than 1 year (12%) to between 2

and 5 years (22%), between 5 and

10 years (19%), between 10 and

15 years (23%), and more than 15

years (23%).

Item Clustering

Factor analyses on all attitude and

social influence items led to 3(AttTime, AttMoral, and AttUse) and 4 (SocNorm, Soc-

Supp, SocPress, and SocRole) interpretable subscales,

respectively (Table 1). For the determinant self-effi-

cacy, no interpretable subscales could be found,

leading to only 1 scale (EffTOT).

Questionnaire Reliability

The paired-samples ttest proved the question-

naire to be stable. No systematic differences (data

not shown) were found except for Attmoral (mean

score before, 2.23 [SD, 0.81]; mean score after, 1.99

[SD, 0.69], P= .02, n= 54). Knowledge scores differed

borderline significantly from before to after the test

(mean score before 6.43/12 [SD, 1.65], mean score

after 7.02/12 [SD, 2.19], P= .05, n = 56).

Finally, an intraclass correlation test indicated

acceptable correlations for almost all determinants

(0.60), except for AttUse (0.30), Soc-

Norm (0.48), and KnowTOT(0.53).

Identification and Evaluation of

Determinants

Self-reported Compliance. Overall

compliance (12 questions) was scored

at 92%. Because of extremely high

scores (>97.8%), 4 items (ie, blood

contact, mucosal contact, macro-

scopically visible contamination/

pollution, and direct contact with body fluids)

were removed from the questionnaire; the final com-

pliance subscale thus consisted of 8 questions.

Data from an observational study24 in the same

ICU enabled us to recalculate the self-reported com-

pliance rates, taking into account the occurrence rate

of each item. Thus, corresponding weights were given

to the 8 remaining items. The recalculated overall

self-reported compliance rate was 82.0% (SD, 15.09%;

n = 105). Rates ranged from 79.2% (SD, 21.4%) for

contaminated surface contact to 98.8% (SD, 6.8%)

for blood contact and 98.8% (SD, 6.6%) for

macroscopic dirt contact.

Behavioral Determinants of Attitude, Social Influence,and Self-efficacy. On a scale ranging from 1 to 5, the

overall attitude toward hand hygiene scored 3.89.

The overall social influence as experienced by the

respondents scored 3.27. The global self-efficacy

scored 3.55. We also calculated the scores for the

different subscales (as shown and commented on in

Table 1) and looked more closely at a number of

scores on the item level. For example, work pressure

did not prove to influence hand hygiene behavior.

Also, nurses were convinced of the necessity and

effectiveness of proper hand hygiene, but they

clearly underestimated the consequences of poorcompliance and tended to minimize the problem.

Knowledge of Hand Hygiene and Integrity of Knowl-

edge Items. On average, the respondents scored 6.5/12

(SD, 1.76, n=107) or 54% on the 12-item knowledge

test. Integrity scores (pivalues) varied from 0.12 to

0.87 (12% to 87% correct answers). Two questions

were found more difficult than expected: one item

regarding the effectiveness of alcohol-based hand dis-

infection (pi =0.12, Alcohol-based hand disinfection

solution has good or excellent antimicrobial effect on

the following organisms, except for [answering pos-

sibilities]) and a second item regarding contamina-

tion rates for Methicillin-resistantStaphylococcus aureus

(MRSA, pi = 0.26, Which percentage of the popula-

tion is represented by MRSA-contaminated? [answer-

ing possibilities]). One question was found easier

than expected (pi = 0.87, Most MRSA cases can be

treated successfully with one of the following antibi-

otics: [answering possibilities]). Values ofdwere

bad/mediocre (d = 0.09) for 2 items and mediocre/

satisfying for another 2 items (d = 0.16). All other

items had satisfying to very good dvalues.

Predictors of Noncompliance

Univariate analysis of the relationship between

the psychosocial constructs and the self-reported

compliance yielded 3 variables that were signifi-

cantly correlated (Table 2). These variables were

included in a multiple linear regression analysis

(Table 3), which identified 2 major determinants as

possible predictors of noncompliant hand hygiene

behavior: self-efficacy ( = .379; P= .001) and AttTime(=-.147; P< .001). Hence, ICU nurses reporting

poor self-efficacy or attitude toward time-related

barriers appear to be less compliant.


This questionnaireidentified the

impact of behav-oral determinantson hand hygiene

compliance.

Behavioralbeliefs are

of greatimportance inhand hygiene

compliance.

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6/11

It is well known that when self-reporting

behavior is used, respondents tend to overscore

socially desirable behavior at up to 3 times the

observed compliance rates.25,26 Respondents also

seem to have unrealistic estimations of their own

behavior.5,27,28 Compared with the direct observation

DiscussionValidation of the Questionnaire

This article describes the development of a self-

administered questionnaire on hand hygiene for

ICU nurses. The questionnaire proved to be of use

for its specific purpose but has some limitations.


Table 1

Description of dependent and independent variables of hand hygiene compliance

Abbreviation Full name Item exampleExplanationNo. of

items

Test score,

mean (SD)

(n=108)

Cronbach

(test)a

(n=108)

Intraclass

correlation

(n=57)

Variable

Compliance

ComTOT

Attitude

AttTime

AttMoral

AttUse

Social influence

SocNorm

SocSupp

SocPress

SocRole

Self-efficacy

EffTOT

Knowledge

KnowTOT

Totalcompliance

Time-relatedattitudeitems

Morality-related

attitude items

Usefulness-related

attitude items

Normative behavior

social influence items

Support-relatedsocialinfluence items

Pressure-relatedsocial

influence items

Role modelrelated

social influence items

Totalself-efficacy

Totalknowledge

The self-reported total

compliance (mean)

Attitude toward handhygiene: taking thetime aspect intoaccount

Attitude toward handhygiene: taking themoral aspect intoaccount

Attitude toward hand

hygiene: taking theusefulness aspectinto account

Social influence on thework floor: ruling norm

Social influence on thework floor: positivefeedback on goodbehavior

Social influence on the

work floor: negativefeedback on poorbehavior

Social influence on thework floor: presenceof role models

Self-efficacy: perceptionof being able tobehave as desired

Total knowledge(mean score for the

12 knowledge items)

82.0%

(15.1%)

2.14(0.8)

2.09(0.8)

1.33

(0.6)

4.16(0.8)

3.80(1.0)

2.34

(1.1)

3.71(0.62)

3.55(1.01)

6.5(1.7)

0.74

0.52

0.66

0.66

0.78

0.86

0.68

0.30

0.48

0.63

0.73

0.64

0.65

0.53

How often do you wash or

disinfect hands in the fol-lowing situations:skincontact

Washing hands wheneverrecommended wouldmean precious loss of timeto me

Washing hands saves livesI feel bad when not

being able to washhands sufficiently

I am not completely con-

vinced of the usefulnessand importance of handhygiene

Most of my colleagues thinkthat hand hygiene prescrip-tions should be adhered toas well as possible

Good hand hygiene prac-tice is appreciated by myprofessional environment

I receive remarks from

colleagues or superiors ifnoncompliant

Most of my colleagues are+50% compliant withhand hygiene

I would wash hands moreoften when more sinks anddispensers were available

Hand disinfection bymeans of an alcohol-based

hand rub is appropriate inthe following situationsexcept for

a Dashes indicate data not reported.

8

5

3

1

1

1

1

4

10

12

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method (the gold standard) or indirect measure-

ment of hand hygiene compliance, self-reported

compliance has appeared to have poor validity in

several studies.29 Unfortunately, no standardized

method for measuring compliance is available.29

The compliance was to be scored from 0% to

100% for 12 specific situations. One may questionif these situations represent all possible situations

in which hand hygiene is indicated. Hand hygiene

prescriptions show great variations between differ-

ent countries and therefore also between hospitals.30

Recalculation of the scores with adjustment for occur-

rence rate certainly contributed to diminishing the

response bias to which our results were prone.

It can be assumed that the time interval between

test and retest has led to communication and even

discussion between the respondents on subjects

related to hand hygiene. A small improvement in

hand hygiene knowledge can therefore be attributed

to the time frame of our study. In any event, general

knowledge about hand hygiene practice appears to

be rather low. An identical observation has been

made previously in more specific areas of infection

prevention, such as infections related to central venouscatheters and ventilator-associated pneumonia.31-35

Also, ones attitude toward the usefulness of hand

hygiene or even the ruling social norm (what others

think should be done) may not be insensitive to the

effects of the interval period, which would explain

the rather poor intraclass correlation coefficients.

The initial questionnaire was found too extensive

and therefore somewhat boring to fill out. Our inves-

tigation allowed us to significantly reduce the number

of items as well as the total length of the questionnaire.

Table 2

Univariate relationships between potential behavioral predictorsand self-reported hand hygiene compliance (Pearson correlation)

Predictora AttTime AttMoral AttUse SocNorm SocSupp SocPress SocRole EffTOT KnowTOT

ComTOT

AttTime

AttMoral

AttUse

SocNorm

SocSupp

SocPress

SocRole

EffTOT

KnowTOT

-0.410b

1

-0.259c

0.133

1

0.075

0.111

0.111

1

0.181

-0.136

-0.244d

-0.254d

1

0.065

-0.063

-0.179

-0.013

0.293c

1

0.131

-0.003

-0.184

0.054

0.161

0.124

1

-0.010

-0.040

-0.143

-0.137

0.669b

0.325b

0.201d

1

0.507b

-0.632c

-0.236d

-0.159

0.336b

0.151

0.123

0.274c

1

0.054

-0.132

-0.062

-0.310b

0.065

0.145

0.077

0.116

0.144

1

aSee Table 1 for an explanation of abbreviations.b Correlation significant up to .001 level.c Correlation significant up to .01 level.d Correlation significant up to .05 level.

Table 3

Linear regression analysis demonstrating adjustedrelationships with total hand hygiene compliance

Independent variable B Standard error

Nonstandardized

coefficientsStandardized

coefficients

Beta Pafter exclusion EffTOTPt

Attitude toward hand hygiene: taking thetime aspect into account (AttTime)

Attitude toward hand hygiene: taking themoral aspect into account (AttMoral)

Self-efficacy: perception of being able tobehave as desired (EffTOT)

-.111

-.120

.412

.082

.069

.121

-.147

-.151

.379

-1.352

-1.737

3.414

.18

.09

.001


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and perceived good adherence to guidelines for

hand hygiene among colleagues.

Self-efficacy. Global hand hygiene self-efficacy

was scored positively. As reported in other studies,15,16

self-efficacy can be improved by observational learn-

ing (ie, social learning, modeling) and practice.

According to Pittet and OBoyle, positive feed-back and subsequent remuneration play a crucial

role in achieving higher self-efficacy.9,39,48,49Although

a recent study50 showed no significant improvement

in hand hygiene through feedback of process meas-

ures, programs consisting of a combination of edu-

cation and frequent performance feedback did lead

to sustained improvement in hand hygiene compli-

ance51 or improved behavior among health care

workers.52According to Sax et al,47

adherence is also driven by the per-

ception of high self-efficacy, rather

than reasoning about the impact ofhand hygiene on patient safety.

Determinant Mixture?We believe

that behavioral beliefs are of great

importance in hand hygiene compli-

ance. Most successful interventions

appear to be ones that include dif-

ferent paths in achieving a behav-

ioral change. A combination of educational

programs, the formation of a multidisciplinary

quality improvement team, compliance monitoring,

and feedback has already proven effective.52As con-

firmed in the same study, evidence-based behavioral

interventions are of growing importance.

Instead of measuring compliance, it appears

worthwhile to have a closer look at the rationale

behind unacceptable low compliance with recom-

mendations for hand hygiene. Motivations and bar-

riers to compliance are to be studied on a higher level.

Our results plead for a change of focus: future

surveillance of hand hygiene (including monitoring

and observation, the gold standard) and evaluation

of campaigns should include systematic follow-up

of the ruling social norm, attitudes, and self-efficacy.

Possible next steps include experimental research

in which the effects of feedback and reward on thenurses self-efficacy can be studied. Also, the spe-

cific role and contribution of ones attitude require

further study through qualitative research such as

focus groups.

ConclusionsWe designed a valid questionnaire to identify

the impact of behavioral determinants on compli-

ance with recommendations for hand hygiene. This

questionnaire can be used for further exploration.

Analysis of Behavioral Determinants

We found that time-related attitude items and

ones self-efficacy were strong predictors of hand

hygiene behavior. Neither social influence nor knowl-

edge of hand hygiene guidelines seem to be of any

predictive value.

Attitude. Our respondents overall attitude towardhand hygiene was rather positive. The ICU is known

to be stressful and to have more opportunities for

hand hygiene than other settings. However, increased

work pressure in the ICU did not seem to have a

direct influence on hand hygiene behavior. This

finding contradicts several reports that identified a

high pressure work environment as having a highly

negative influence on hand hygiene.1,8,36-39(p165) Hand

hygiene compliance also seemed to be insensitive

to the moment of care (not associated with a certain

part of the day).

Use of irritating and drying solutions for handdisinfection was identified as a barrier to proper

hand hygiene. Thus, as confirmed by many other

studies37,40-43 providing sufficient and easy-to-access

skin-friendly products might result in higher com-

pliance with recommendations for hand hygiene.

Although the respondents attitudes proved to

be at an acceptable level, further and ongoing

improvement can be worthwhile. Improving ones

attitude on a long-term basis could be effective

through intensive training and subsequent increase

of ones knowledge.44,45According to Larson et al,46

focusing on knowledge in order to improve ones

attitude should not be effective. Recently a study11

showed that feelings of unpleasantness, discomfort,

and/or disgust lead to emotional sensations that

invoke self-protection and therefore can help in

improving ones attitude toward good hand hygiene

practice.

Social Influence.The answers indicate an overall

neutral to positive ruling social norm. Social pres-

sure was low: the nurses reported that noncompli-

ance does not easily lead to negative feedback or a

remark from a colleague or from a staff member.

Furthermore, in our study, social influence had no

predictive value. According to Whitby et al,11 a focuson role modeling, peer pressure, education of

health care workers, and ongoing cues to action,

such as posters or easy access to hand rubs can lead

to persistent behavioral change.

Sax et al47 identified highly ranked normative

beliefs as well as perceived social pressure as predic-

tors of compliance with guidelines for hand hygiene.

In the same study, high self-reported rates of adher-

ence to hand hygiene were independently associated

with female sex, receipt of training, peer pressure,


It is worthwhileto look at therationale behindunacceptably lowhand hygienecompliance.

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Our preliminary results show that a low self-efficacy

and a negative attitude toward time-related barriers

are predictors of poor compliance with recommen-

dations for hand hygiene.

ACKNOWLEDGMENTSThis paper was presented at the 45th Interscience Con-

ference on Antimicrobial Agents and Chemotherapy,Washington, DC, United States, December 16-19, 2005.

FINANCIAL DISCLOSURESNone reported.

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31. Labeau S, Vereecke A, Vandijck DM, Claes B, Blot SI. Criticalcare nurses knowledge of evidence-based guidelines forpreventing infections associated with central venouscatheters: an evaluation questionnaire. Am J Crit Care.2008;17:65-72.

32. Blot SI, Labeau S, Vandijck D, Van Aken P, Claes B; Execu-tive Board of the Flemish Society for Critical Care Nurses.Evidence-based guidelines for the prevention of ventilator-associated pneumonia: results of a knowledge test amongintensive care nurses. Intensive Care Med. 2007;33:1463-1467.

33. Labeau S, Vandijck DM, Claes B, van Aken P, Blot SI. Criticalcare nurses knowledge of evidence-based guidelines forpreventing ventilator-associated pneumonia: an evaluationquestionnaire. Am J Crit Care. 2007;16:371-377.

34. Labeau S, Vandijck D, Rello J, et al. Evidence-based guide-lines for the prevention of ventilator-associated pneumonia:results of a knowledge test among European intensive carenurses. J Hosp Infect. 2008;70:180-185.

35. Labeau S, Vandijck DM, Rello J, et al. Centers for DiseaseControl and Prevention guidelines for preventing centralvenous catheter-related infection: results of a knowledgetest among 3405 European intensive care nurses. Crit CareMed. 2009;37:320-323.

36. Coignard B, Grandbastien B, Berrouane Y, et al. Handwashingquality: impact of a special program. Infect Control HospEpidemiol. 1998;19:510-513.

37. Hirsch J. Compliance with hand hygiene protocol by nursesin a Dutch hospital. J Hosp Infect. 1999;43:163-164.

38. Larson E, Killien M. Factors influencing handwashing behav-ior of patient care personnel. Am J Infect Control. 1982;10:93-99.

39. OBoyle C. Variables that Influence Health Care WorkersAdherence to Recommended Handwashing Practices[dis-sertation]. Minneapolis, MN: University of Minnesota; 1998.

40. Larson E, Friedman C, Cohran J, Treston-Aurand J, GreenS. Prevalence and correlates of skin damage on the handsof nurses. Heart Lung. 1997;26:404-412.

41. Larson E, McGinley KJ, Grove GL, Leyden JJ, Talbot GH. Phys-iologic, microbiologic, and seasonal effects of handwashing

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wash their hands: a standardized measurement approach.Appl Nurs Res. 2001;14:136-145.

49. OBoyle CA, Henly SJ, Larson E. Understanding adherenceto hand hygiene recommendations: the theory of plannedbehavior. Am J Infect Control. 2001;29:352-360.

50. Berhe M, Edmond MB, Bearman G. Measurement andfeedback of infection control process measures in theintensive care unit: impact on compliance. Am J InfectControl. 2006;34:537-539.

51. Rosenthal VD, Guzman S, Safdar N. Reduction in nosoco-mial infection with improved hand hygiene in intensivecare units of a tertiary care hospital in Argentina. Am JInfect Control. 2005;33:392-397.

52. Aboelela SW, Stone PW, Larson EL. Effectiveness of bundledbehavioural interventions to control healthcare-associatedinfections: a systematic review of the literature. J HospInfect. 2007;66:101-108.

on the skin of health care personnel. Am J Infect Control.1986;14:51-59.

42. Seitz JC, Newman JL. Factors affecting skin condition intwo nursing populations: implications for current hand-washing protocols. Am J Infect Control. 1988;16:46-53.

43. Zimakoff J, Kjelsberg AB, Larsen SO, Holstein B. A multi-center questionnaire investigation of attitudes toward handhygiene, assessed by the staff in fifteen hospitals in Den-mark and Norway. Am J Infect Control. 1992;20:58-64.

44. Colombo C, Giger H, Grote J, et al. Impact of teachinginterventions on nurse compliance with hand disinfection.J Hosp Infect. 2002;51:69-72.

45. Pittet D, Boyce JM. Revolutionising hand hygiene in health-care settings: guidelines revisited. Lancet Infect Dis. 2003;3:269-270.

46. Larson EL, Bryan JL, Adler LM, Blane C. A multifacetedapproach to changing handwashing behavior. Am J InfectControl. 1997;25:3-10.

47. Sax H, Uckay I, Richet H, Allegranzi B, Pittet D. Determinantsof good adherence to hand hygiene among healthcare work-ers who have extensive exposure to hand hygiene cam-paigns. Infect Control Hosp Epidemiol. 2007;28:1267-1274.

48. OBoyle CA, Henly SJ, Duckett LJ. Nurses motivation to

To purchase electronic or print reprints, contact TheInnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax,(949) 362-2049; e-mail, [email protected].

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Name Member #Address

City State ZIP

Country Phone E-mail address

RN License #1 State

RN License #2 State

Payment by: K Visa K M/C K AMEX K Check

Card # Expiration Date

Signature

CE Test Test ID A1019033: Behavioral Determinants of Hand Hygiene Compliance in Intensive Care Units. Learning objectives: 1. Recognize theimpact of behavioral determinants on compliance with hand hygiene recommendations. 2. Describe determinants of noncompliance with hand hygiene prescrip-tions among nurses in a general intensive care unit. 3. Understand how a low self-efficacy and a negative attitude toward time-relatedbarriers are predictors of poorcompliance with hand hygiene recommendations.

Program evaluation Yes NoObjective 1 was met K KObjective 2 was met K KObjective 3 was met K KContent was relevant to my

nursing practice K KMy expectations were met K KThis method of CE is effective

for this content K KThe level of difficulty of this test was:

K easy K medium K difficultTo complete this program,

it took me hours/minutes.

1. The questionnaire was based on which of the following models?a. Quality management modelb. Stages of change modelc. Consumer information processing modeld. Behavioral theory model

2. Which of the following is the most effe ctive measure toprevent cross-contamination?a. Transmission-based precautionsb. Hand hygienec. Personal protective equipmentd. Appropriate disinfection of reusable equipment

3. Which of the following is the reported compliance withappropriate hand hygiene practices?a. 10% to 20% c. 50% to 60%b. 30% to 40% d. 70% to 80%

4. Which of the following refers to the belief in ones ability tobehave as desired and to overcome certain barr iers?a. Self-determinationb. Self-efficacyc. Self-conceptd. Self-actualization

5. The items on the knowledge scale were selected from a validatedquestionnaire on hand hygiene from which of the followingorganizations?a. Centers for Disease Control and Preventionb. World Health Organizationc. The Joint Commissiond. Institute for Healthcare Improvement

6. What was the recalculated overall self-reported compliance rate?a. 79.2% c. 92.7%b. 82.0% d. 98.8%

7. Which of the followi ng was identif ied as one of the strongestpredictors of hand-hygiene behavior?a. Self-efficacyb. Social influencec. Moral perceptions

d. Knowledge of hand hygiene guidelines

8. What did researchers find related to attitude and handhygiene?a. Increased work pressure had a highly negative influence on hand

hygiene.b. Hand hygiene compliance was associated with a certain part of the

day.c. No barriers to proper hand hygiene were identified.d. Respondents overall attitude toward hand hygiene was rather

positive.

9. Which of the following was a study finding about social

inf luence and hand hygiene behavior?a. Social pressure was high among respondents.b. Social influence was a strong predictor of compliance.c. Answers indicated an overall neutral to positive ruling social norm.d. Noncompliance easily led to negative feedback.

10. Washing hands saves lives is an item example of whichvariable?a. Morality-related attitudeb. Total compliancec. Time-related attituded. Usefulness-related attitude

11. Which of the following social inf luence variables is explainedas the ruling norm?a. Support-relatedb. Pressure-relatedc. Normative behaviord. Role model-related

For faster processing, takethis CE test online at

www.ajcconline.org (CEArticles in This Issue) ormail this entire page to:AACN, 101 Columbia,Aliso Viejo, CA 92656.

Fee: AACN members, $0; nonmembers, $10 Passing score: 8 Correct (73%) Synergy CERP: Category A Test writer: Denise Hayes, RN, MSN, CRNP

The American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.

AACN has been approved as a provider of continuing education in nursing by th e State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACNprogramming meets the standards for most other states requiring mandatory continuing education credit for relicensure.

Test ID: A1019033 Contact hours: 1.0 Form expires: May 1, 2012.Test Answers: Mark only one box for your answer to each question. You may photocopy this form.

1. KaKbK cKd

9. KaKbK cKd

8. KaKbK cKd

7. KaKbK cKd

6. KaKbK cKd

5. KaKbK cKd

4. KaKbK cKd

3. KaKbK cKd

2. KaKbK cKd

11. KaKbK cKd

10. KaKbK cKd
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