Understanding Practice: Factors That Influence Physician Hand Hygiene Compliance

Janet E. Squires, PhD; Stefanie Linklater, MSc; Jeremy M. Grimshaw, PhD; Ian D. Graham, PhD; Katrina Sullivan, MSc; Natalie Bruce, MScN; Kathleen Gartke, MD; Alan Karovitch, MD; Virginia Roth, MD; Karen Stockton, MHSc; John Trickett, BScN; Jim Worthington, MD; Kathryn N. Suh, MD


Infect Control Hosp Epidemiol. 2014;35(12):1511-1520. 

In This Article

Abstract and Introduction


Objective To identify the behavioral determinants—both barriers and enablers—that may impact physician hand hygiene compliance.

Design A qualitative study involving semistructured key informant interviews with staff physicians and residents.

Setting An urban, 1,100-bed multisite tertiary care Canadian hospital.

Participants A total of 42 staff physicians and residents in internal medicine and surgery.

Methods Semistructured interviews were conducted using an interview guide that was based on the theoretical domains framework (TDF), a behavior change framework comprised of 14 theoretical domains that explain health-related behavior change. Interview transcripts were analyzed using thematic content analysis involving a systematic 3-step approach: coding, generation of specific beliefs, and identification of relevant TDF domains.

Results Similar determinants were reported by staff physicians and residents and between medicine and surgery. A total of 53 specific beliefs from 9 theoretical domains were identified as relevant to physician hand hygiene compliance. The 9 relevant domains were knowledge; skills; beliefs about capabilities; beliefs about consequences; goals; memory, attention, and decision processes; environmental context and resources; social professional role and identity; and social influences.

Conclusions We identified several key determinants that physicians believe influence whether and when they practice hand hygiene at work. These beliefs identify potential individual, team, and organization targets for behavior change interventions to improve physician hand hygiene compliance.


Hand hygiene is recognized globally as a leading measure to reduce healthcare-associated infection.[1–4] Hand hygiene compliance, however, is unacceptably low.[5,6] Physicians in particular are repeatedly observed as being poor compliers.[6] Promotion of hand hygiene is a complex issue.[2] To develop interventions with more pronounced and sustainable effects, knowledge of the behavioral determinants to hand hygiene is needed.[7] While factors related to nurses' noncompliance has been studied frequently,[7–9] reasons for low compliance among physicians are less well understood. Studies investigating healthcare workers generally (which sometimes include a small sample of physicians) have reported a range of barriers, including environmental (eg, lack of access to sinks, difficulty of locating products, empty or broken dispensers, and time constraints) and personal (eg, attitudinal beliefs, skin irritation from repeated hand washing) barriers.[10,11] Additional barriers specific to physicians identified or postulated include educational gaps in infection control training,[12–14] a perception that their compliance is better than it actually is,[15,16] a more cavalier attitude toward infection control with experience,[17,18] a lack of positive physician role models,[18–20] and the local (eg, unit, hospital) culture of patient safety.[21]

We located only 1 study that explicitly used behavioral theory to study hand hygiene compliance among physicians. Erasmus et al[7] conducted a qualitative study framed by the theory of planned behavior; findings showed that physicians felt hand hygiene was important for self-protection but that there was little evidence that handwashing is effective in preventing cross-infection. Residents/medical students also stated said that they copy the behavior of their superiors, which often leads to their noncompliance.[7]

The purpose of this study was to identify the behavioral determinants—both barriers and enablers—to physician hand hygiene compliance at 1 tertiary care hospital. The theoretical domains framework (TDF), which is a behavior change framework, guided the study. The TDF was selected because of it comprehensiveness; it represents an agreed set of key theoretical constructs that can be used to identify all (rather than a subset) of possible barriers and enablers to healthcare professional behaviors, such as hand hygiene. The TDF was developed jointly by health psychology theorists, health services researchers, and health psychologists and comprises 14 theoretical domains derived from 128 constructs from 33 different health, behavioral, and social psychology theories that explain health-related behavior change (Table 1).[22,23] The TDF has been used previously to successfully identify the determinants of a wide range of healthcare professional behaviors, including hand hygiene with nurses.[9,24] This is the first application of the TDF specific to physician hand hygiene compliance.