Journal of Hospital Infection xxx (xxxx) xxx

Available online at www.sciencedirect.com

Journal of Hospital Infection

journal homepage: www.elsevier.com/locate/jhin

Short report

One size does not fit all: the effectiveness of messaging

for hand hygiene compliance by profession in a tertiary
hospital
S. Salmon a, *, M.Y. Phua b, D. Fisher c, d
a
Infection Prevention Team, Nursing Administration, National University Hospital, Singapore
b
Faculty of Arts and Social Sciences, Department of Sociology, National University of Singapore, Singapore
c
Division of Infectious Diseases, University Medicine Cluster, National University Hospital, Singapore
d
Yong Loo Lin School of Medicine, National University of Singapore, Singapore

A R T I C L E I N F O S U M M A R Y

Article history: To determine the effectiveness of our messaging for hand hygiene compliance by pro-
Received 15 July 2019 fession, we conducted a hospital-wide survey followed by profession-specific focus group
Accepted 9 September 2019 discussions to investigate impact, perceptions and areas for improvement. Results showed
Available online xxx a good understanding that hand hygiene is a crucial part of the infection-prevention
programme; however, the acceptance and impact of messages varied between pro-
Keywords: fessions and required tailoring. Motivation, use of influential role models and social
Infection control cohesion should be considered when designing profession-specific messages to improve
Hand hygiene infection-prevention-related change uptake among healthcare professional groups.
Behaviour ª 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Social cohesion
Programme evaluation

Background implementation, uptake by healthcare workers (HCWs)

remains poor and guidelines are often questioned.
Infection prevention programmes particularly compliance In 2010, the National University Hospital (NUH), as part of an
to hand hygiene are effective in reducing the spread of aggressive campaign to reduce methicillin-resistant Staph-
healthcare-associated infections and decreasing mortality [1]. ylococcus aureus (MRSA) transmission, introduced an enhanced
Despite established effectiveness of these programmes hand-hygiene programme with a strong emphasis on using
including evidence-based recommendations on the core com- evidence-based multi-faceted and multi-modal strategies
ponents for infection prevention and control (IPC) programmes [3,4]. Since programme inception, a multitude of activities
[2], healthcare institutions struggle with successful have been implemented to encourage HCWs to perform hand
hygiene according to the WHO ‘My Five Moments for Hand
Hygiene’. Activities were designed and structured similarly to
* Corresponding author. Address: Nursing Administration, National the later-published WHO hand hygiene multi-modal improve-
University Hospital, Singapore. Tel.: þ65 911 58777. ment strategy incorporating: system change, training and
E-mail address: [email protected] (S. Salmon).

https://doi.org/10.1016/j.jhin.2019.09.008
0195-6701/ª 2019 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Salmon S et al., One size does not fit all: the effectiveness of messaging for hand hygiene compliance by profession in a
tertiary hospital, Journal of Hospital Infection, https://doi.org/10.1016/j.jhin.2019.09.008
2 S. Salmon et al. / Journal of Hospital Infection xxx (xxxx) xxx
education, observation followed by evaluation and feedback, approximately 60 min (four nursing, two doctor and two allied
workplace reminders, and institutional safety climate [3]. health groups).
Since 2010, infection-control liaison nurses have been Audiotapes of the sessions were transcribed verbatim. A
trained to conduct monthly cross-ward audits using the WHO trained moderator facilitated all sessions supported by two
hand hygiene tool to measure hand hygiene compliance rates. note-takers. Transcripts were read independently by the lead
Collated results are reported quarterly, by ward, discipline and facilitator and expert present in all discussions. Transcripts
overall hospital-wide. The hospital compliance target is set at were examined separately by profession. Once themes were
75%. In 2014, the NUH hand-hygiene compliance rate was 85% agreed on, both researchers read and coded all transcripts. Key
(2185/2559). By profession, compliance rates were: doctors themes were identified across all professional groups.
60% (1049/1756), nurses 78% (4967/6384) and allied health 74% Each discussion group was presented with the results from
(369/498). Despite achieving the target, the NUH Infection the hand-hygiene section of the survey, with responses com-
Prevention Team continued to strive to reach higher com- pared by professions. Findings were presented based on
pliance for all professional groups. HCWs come from varied response rates. Discussion questions were derived from the
ethnic, socioeconomic, cultural or educational backgrounds initial survey and covered the type and delivery of hand
however such factors are rarely incorporated when designing hygiene messages, how they were communicated, their
and implementing multimodal behaviour-change strategies. appropriateness and the targeted behaviour determinant.
Improving HCWs’ hand-hygiene compliance implies behaviour
change; therefore, application of knowledge from the behav-
ioural and social sciences seems intrinsically valuable [5]. Results
The objective of this study was to determine the effec-
tiveness of our messaging for hand-hygiene compliance by Survey
profession to investigate impact, perceptions, and identify
areas for improvement. Results revealed that HCWs acknowledge the serious
consequences of developing a hospital-acquired infection.
However, 35% (52/147) of doctors, 32% (66/203) of allied
Methods health workers and 20% (191/931) of nurses admitted to
omitting hand hygiene in preference to focussing on the
We surveyed 1700 randomly selected HCWs, representing 30% clinical task. Similarly, 35% (52/147) of doctors, 40% (83/
for each job category, from the list of all hospital ward-based 203) of allied health workers and 25% (239/931) of nurses
nurses, doctors and allied health workers. Surveys were vali- struggled to remember the right ‘moment’ to perform hand
dated by hospital IPC experts and tested on HCWs prior to dis- hygiene. Nurses are the most engaged in the hospital hand-
semination. Surveys were hand delivered and collected by hygiene programme, including identifying ward hand-
dedicated project team members, external to the organization. hygiene champions. Interventions to motivate hand-
On collection, coffee vouchers were given to participants for hygiene compliance varied between professions with 56%
survey completion. Project team members were allocated spe- (523/931) of nurses strongly encouraged by dance videos or
cific ward and surveys were delivered on specific dates to HCWs fun activities whereas 80% (118/147) of doctors and 55%
on duty until desired participation numbers were achieved. A (112/203) of allied health professionals preferred serious
total of 931/1100 (84.6%) nurses, 147/300 (49.7%) physicians and messages via scientific presentations or e-mails.
203/300 (67.7%) allied health staff (radiographers, physi-
otherapists, speech and respiratory therapists) responded. The
Focus groups
survey consisted of 37 questions and was divided into three
categories: hand-hygiene interventions, environmental cleaning Examination of the focus-group discussion transcripts for
and single-use receptacle management [6]. Allied health staff themes revealed that the unifying concept was the need for
and doctors completed the hand-hygiene section only. Eleven profession-specific tailored hand-hygiene messages. Addition-
questions were included for the hand-hygiene section. Questions ally, the importance of an influential role model to promote
focussed on common sentiments expressed about the practice of hand hygiene and a sense of belonging to a supportive work-
the Five Moments of Hand Hygiene; awareness of NUH hand- place environment to facilitate reminding and encouraging
hygiene programmes, initiatives and information sources; HCW performing hand hygiene were reoccurring themes.
perception of hand-hygiene compliance; barriers and facilitators
to hand-hygiene compliance and helpful NUH initiatives to pro-
mote and motivate hand hygiene. Theme 1: Need for profession-specific tailored
Reponses were measured using a 5-point Likert scale (1 ¼ messages
strongly agree, 2 ¼ agree, 3 ¼ disagree, 4 ¼ strongly agree, and
5 ¼ do not know). There was capacity for free text feedback. Many HCWs expressed the need for hand-hygiene messages
Hand-hygiene intervention findings were categorized by (1) to evoke emotions to transform the current mindset. Hand-
beliefs and practices, (2) awareness of hand-hygiene pro- hygiene campaigns and messages were criticized for not
grammes, and (3) evaluation of programmes. being serious and not describing the mortality associated with
Eighty survey respondents who indicated willingness to be poor hand-hygiene compliance. HCWs described a disconnect
involved in further discussion subsequently participated in with the messages due to a lack of involvement in their design
profession-specific focus groups to discuss hand-hygiene and delivery.
interventions. Each focus group discussion lasted

Please cite this article as: Salmon S et al., One size does not fit all: the effectiveness of messaging for hand hygiene compliance by profession in a
tertiary hospital, Journal of Hospital Infection, https://doi.org/10.1016/j.jhin.2019.09.008
 S. Salmon et al. / Journal of Hospital Infection xxx (xxxx) xxx 3

Table I
Overview of the National University Hospital implemented hand-hygiene programme, evolving since 2006 based on WHO multi-modal
improvement strategy with behaviour change techniques and their determinants
WHO 5 elements Behaviour Behaviour change NUH activity
determinants technique
Training Education Knowledge General information Annual event: exhibits, scientific presentation
Updates on evidence Biennial hand-hygiene assessment
Training: orientation, students, senior residents, infection-control
liaison nurses
Dedicated marks in medical exams
Medical & nursing observational learning via audits integrated in
training
Observation followed Awareness Risk communication Hospital-wide compliance results by ward & profession
by evaluation and Direct & delayed Epidemiology reports
feedback feedback of Cross-ward audits with feedback
behaviour
System change Social influence Opportunities for Compliance results posted in all inpatient wards
social comparison Senior Hospital leader video messages e links:
Nursing: https://www.youtube.com/watch?v=5q3Z4eu15RA
Specialty Outpatient Clinic: https://www.youtube.com/watch?
v=kfMQR4lljmQ
Clinical Support Services: https://www.youtube.com/watch?
v=EL4xBx9J8aE
Environmental Services: https://www.youtube.com/watch?v=nd_
LRkCXmQQ
Paediatric Cluster: https://www.youtube.com/watch?
v=cIxQbqqogvQ
Medical Students: https://www.youtube.com/watch?v=6Uc8jr6EBTA
University Medicine Cluster: https://www.youtube.com/watch?
v=xFEq_e5BxfY
University Surgical Cluster: https://www.youtube.com/watch?
v=X68FI1U-YQo
Attitude Persuasive Awards for consistent hand-hygiene compliance
communication Competitions with prizes
Reinforcement of Commendation & warning letters from senior management for high/
behavioural progress low performance
Workplace reminders Action control Use of cues Posters, computer screens
Reminders at sinks
Institutional safety Facilitation of Materials to facilitate Alcohol-based hand rub at bedside
climate behaviour behaviour Tiered escalation of audits during outbreaks
Continuous Reimbursement of physician medical insurance after hand-hygiene
professional support assessment
Hospital performance target
Intention Agree to behavioural HCW patient safety pledge
contract
Self-efficacy Role models Nominated nurse & clinician champions
HCW, healthcare worker.

Junior nurses: ‘We [allied health] are left behind many times and don’t know how
to get information.’
‘The [Hand Hygiene] programme has to make sense and evoke
emotions. Sometimes it’s [the hand hygiene message] too serious
Senior physician:
and too stressful.’
‘I think the dancing doesn’t really emphasize the importance of
‘It must have impact [the hand hygiene message].’
hand hygiene. I think it actually belittles the severity of health care
associated infections.’
Allied healthcare workers:
‘ . it [the hand hygiene programme] just feels not useful for me.’ Junior physician:
‘I know that I need to protect the patient, to prevent infections, but ‘Infection control is under nursing so when they publicise it’s mostly
it [the hand hygiene programme message] doesn’t go into your under nursing and for nurses.’
heart and it doesn’t go into your mind.’

Please cite this article as: Salmon S et al., One size does not fit all: the effectiveness of messaging for hand hygiene compliance by profession in a
tertiary hospital, Journal of Hospital Infection, https://doi.org/10.1016/j.jhin.2019.09.008
4 S. Salmon et al. / Journal of Hospital Infection xxx (xxxx) xxx
Despite ongoing efforts to present literature during a sci- ‘ . if they [doctors] can speak to us [senior nurses] in a rude
entific forum supporting infection-prevention and hand- manner, what about our junior nurses?’
hygiene programmes, HCWs continue to challenge its authen-
ticity and do not understand the causal relationship with Junior physician:
unclean hands and hospital acquired infections. ‘When the senior consultant goes in MRSA [contact precautions]
cubicle and doesn’t want to perform hand hygiene it’s a bit awk-
ward [to remind].’
Junior physician:
Discussions helped us to classify our hand-hygiene
‘[The Infection Prevention programme needs] statistical evidence improvement activities according to the five elements of the
or data to convince us [physicians] of the link between performing WHO multi-modal improvement strategy. We identified eight
hand hygiene and hospital acquired infections.’ determinants of behaviour change and 12 change techniques
used. We identified our programme’s key focus as facilitating
Allied HCW: behaviour change through strengthening the institutional
‘We need to know clearly why hospital infections are important, but safety climate using materials and professional support such as
we can’t understand the same way that it is explained to doctors.’ access to alcohol-based hand rub at each bed, a dedicated
infection-prevention team, medical insurance reimbursement
linked to passing hand-hygiene assessment, establishing a
Theme 2: Influential role models hospital hand-hygiene compliance target and adopting novel
approaches to improve hand hygiene compliance of nursing [8]
Strong effective leaders play an essential role in the success and medical students (Table I).
of an infection-prevention programme including better hand- As a result of the discussion findings, the NUH Infection
hygiene compliance [7]. Participants expressed the need for Prevention Team engaged staff from each healthcare group
senior staff, specifically senior physicians, to practice good (including students) to develop a hand-hygiene video with a
hand hygiene. Senior physicians are regarded as key influencers message from an influential hospital leader (specific to each
to motivate other HCWs to follow their practices and as profession) that includes information chosen by and consid-
behaviour change drivers. ered important by each profession (Table I). The video con-
tinues to be used as a hand-hygiene advocacy tool for all
Junior nurse: professions.
‘It would help if the consultants themselves practise it [hand
hygiene] because even if junior doctors practise it and the senior Discussion
consultant doesn’t practise it, eventually they will adopt his [the
senior consultants] habit.’ The WHO Multi-Modal Strategy [3] serves as a compre-
hensive guide to improve hand-hygiene compliance. However,
Junior physician: based on the focus group discussions, more work is needed for
‘When senior consultants practise [hand hygiene], its inspiring for the strategy to be translated into relevant practice.
everyone.’ Our identified themes complement the findings of Grayson
et al. [9] who describe the importance of understanding
Senior physicians: personality profiles to specific infection-control strategies
with doctors requiring a clear outline of the evidence and the
‘While there are good role models, there also obviously not so good
individual consequences of their adherence to the inter-
role models, and when that happens, that’s when you get people
who don’t believe in it [hand hygiene] anymore.’
vention. Nursing and allied health staff, meanwhile, appear
to be more concerned with outcomes as a collective group and
‘There is also a prevailing feeling that “Oh yeah, it’s the nurses’ are likely to connect with interventions that incorporate
job.” Actually it isn’t . it’s OUR job! I think there’s a lack of emotions and relationships rather than being purely infor-
ownership.’ mation driven.
Our study has several limitations related to the various
levels of seniority and professional hierarchy present within
Theme 3: Encouraging and supportive workplace the group discussions, including the possibility that partic-
environment ipants might have answered according to the group’s social
norms. In addition, discussing challenges and constraints with
While skilled and effective leaders were prominent in the hospital-wide programmes is not common in our context.
discussions, participants reported a strong need for a suppor- Our results provide an insight into the unique personality
tive and cohesive team to facilitate a culture of reminding each differences among HCWs and how this affects the acceptance
other to perform hand hygiene when indicated. and uptake of hand-hygiene interventions. The need for lead-
ers as drivers for change and promoters of social cohesiveness
Senior physician: is sought to help with behaviour change interventions and to
‘Allied health workers and physicians run around many different develop a more supportive organization culture that can be
locations. This is a barrier to building team culture, team discipline continued by the HCWs inside the wards.
and team safety.’ Accounting for professional characteristics can enhance
acceptance of behaviour change interventions that are crucial
Senior nurse: for infection prevention and control programmes. Programme

Please cite this article as: Salmon S et al., One size does not fit all: the effectiveness of messaging for hand hygiene compliance by profession in a
tertiary hospital, Journal of Hospital Infection, https://doi.org/10.1016/j.jhin.2019.09.008
 S. Salmon et al. / Journal of Hospital Infection xxx (xxxx) xxx 5
design must consider the audience e personality, background [4] Fisher D, Tambyah PA, Lin RT, Jureen R, Cook AR, Lim A, et al.
and preference for messaging for impact. Without such con- Sustained methicillin-resistant Staphylococcus aureus control in a
siderations, we are missing the opportunity to engage HCWs hyper-endemic tertiary acute care hospital with infrastructure
and change behaviour. Our discussions showed that a one-size challenges in Singapore. J Hosp Infect 2013;85(2):141e8.
[5] Huis A, van Achterberg T, de Bruin M, Grol R, Schoonhoven L,
programme does not fit all, and adjustments need to be tail-
Hulscher M. A systematic review of hand hygiene improvement
ored for infection-prevention programmes to be successful, strategies: a behavioural approach. Implement Sci 2012;7:92e105.
cost effective and sustainable. [6] Phua MY, Salmon S, Straughan P, Fisher DA. Disposable single-use
receptacles in a tertiary hospital: A large survey of staff after a
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Please cite this article as: Salmon S et al., One size does not fit all: the effectiveness of messaging for hand hygiene compliance by profession in a
tertiary hospital, Journal of Hospital Infection, https://doi.org/10.1016/j.jhin.2019.09.008