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


Inter-rater Agreement

For the last 10 interviews, the inter-rater agreement between the 2 coders responsible for coding utterances in the key informant transcripts into the 14 TDF theoretical domains was excellent (κ = 0.7555 [95% confidence interval, 0.7095–0.8014]). Inter-rater agreement for the 14 TDF domains ranged from 0.4752 to 0.9818 (Table 2). Although this initial inter-rater agreement was calculated, all disagreements between the 2 coders were discussed and resolved through consensus.

Sample Characteristics

A total of 179 participants were approached to recruit 42 key informants. Distribution across the 2 inpatient campuses, specialties (medicine, surgery), and roles (staff physician, resident) were intentionally similar through the use of stratified sampling. Most participants were male (N = 33 [79%]), 40 years of age or younger (N = 23 [55%]), had 10 years experience or less (N = 17 [41%]), and worked at the hospital 5 years or less (N = 20 [48%]; Table 3). Interviews ranged in duration from 13 to 31 minutes, with a mean interview time of 20 minutes.

Relevant Theoretical Domains

Nine of the 14 TDF theoretical domains were identified as relevant to physician hand hygiene compliance: (1) knowledge; (2) skills; (3) beliefs about capabilities; (4) beliefs about consequences; (5) goals; (6) memory, attention, and decision processes; (7) environmental context and resources; (8) social professional role and identity; and (9) social influences. Across these 9 relevant domains, a total of 53 specific beliefs were identified that had a relative frequency of 5 or more or were conflicting beliefs. Table 4 displays the specific beliefs, their frequency (ie, number of interviews in which the belief was mentioned), along with a supportive quote from the interview for each belief.

Differences by Campus, Specialty, and Role

There were no notable differences in the specific beliefs identified across the 2 geographical campuses, specialties (medicine compared with surgery), or role (staff physician compared with resident), with the exception of 1 TDF domain (social influences), where there were differences by specialty.

In the majority of key informant interviews, both patient (N = 15 [36%]) and other team member (N = 15 [36%]) expectations were identified as important influences for physician hand hygiene compliance. Both surgery and medicine participants similarly identified patient's expectations as important, but the influence of other team members was notably stronger in medicine. Only 1 (9%) surgery staff felt that other team members influenced their hand hygiene practice compared with 4 (40%) surgery residents, 5 (45%) medicine staff, and 5 (50%) medicine residents. Similarly, while 18 (43%) of all participants stated that other team members do not influence their practice, twice as many surgery staff (N = 12/21 [57%]) stated this compared with medicine staff (N = 6/21 [29%]).