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


Although hand hygiene is a simple procedure to perform, its application in practice, especially by physicians, is a complex phenomenon not easily explained or changed.[2,28,29] Behavioral research into hand hygiene is therefore highly needed in order to identify the determinants of its use.[7,12,30] To our knowledge, this is the first study to use the TDF to explore the determinants of physician hand hygiene compliance. By using this specific behavioral theory approach, a comprehensive and systematic understanding of the determinants of physician hand hygiene compliance was possible. The determinants—which ranged from individual beliefs to organizational and social contexts—hold potential as targets for behavior change interventions to improve physician hand hygiene compliance.

Previously, Pittet et al[2] conducted a survey of physician practices, beliefs, and attitudes toward hand hygiene. They found that physician compliance with hand hygiene was largely a function of their environmental context, social pressure, perception of risk of cross-contamination, and a positive attitude toward hand hygiene itself. Our study confirmed these findings but explored each determinant in more detail to create specific beliefs around them that can be used in future intervention studies to improve compliance. We also significantly expanded on Pittet's study by identifying many additional barriers as well as enablers to physician hand hygiene compliance. In total, we identified 53 specific physician beliefs from 14 behavioral domains that can be used as targets in future interventions.

Knowledge and skills were important for physician hand hygiene compliance in our study. Consistent with previous research,[2,7] we anticipated finding a knowledge gap with respect to awareness of evidence linking hand hygiene to the development of healthcare-associated infections. However, we did not anticipate a large knowledge gap related to awareness of hand hygiene guidelines or a skill gap in how to properly perform hand hygiene. These behavioral domains have not been previously assessed, perhaps because they are considered basic training for all healthcare providers, including physicians. Their identification in this study, however, warrants their continued investigation and also their consideration as targets for action in interventions to improve physician hand hygiene compliance.

Memory, attention, and decision processes were also important to hand hygiene compliance in this study. It is commonly assumed that all healthcare workers, including physicians, perceive hand hygiene as a routine procedure to carry out when providing patient care; our findings did not support this. In fact, the majority of the physicians interviewed felt hand hygiene required a conscious decision and that reminders to practice hand hygiene were necessary. We located no previous studies that examined the effectiveness of reminders alone to improve physician hand hygiene compliance. However, some studies have found multimodal interventions (which included a reminder component) to be successful.[31,32] In these studies, reminders were in the form of displayed posters. In our interviews and team discussions, visual reminders were also felt to have potential for success; for example, colored stickers on hand hygiene alcohol stations were suggested. Our finding that hand hygiene is not automatic for physicians was also noted in a previous study by Erasmus et al,[7] who found that forgetfulness was a barrier to physician hand hygiene compliance. Interesting, this differs from behavioral hand hygiene research conducted among nurses; Boscart et al,[9] in a similar qualitative study to ours but conducted with nurses, found that hand hygiene was largely a routine and automatic process.

Social influences, particularly of patients and colleagues, were important considerations to physicians in their hand hygiene practice. We located no previous work that investigated the role of patient expectations on physician (or any healthcare providers') hand hygiene behavior. One study examining this influence on nursing hand hygiene did not show patient expectations to be a consideration.[9] Future exploration of the role of patients in influencing physician hand hygiene would be a fruitful avenue for research. There is evidence that supports the influence of colleagues on hand hygiene compliance. Role models are known to play a central role in changing physician behavior generally[2,33] and to improve physician hand hygiene compliance specifically,[2,7,34] yet they are seldom used in interventions to change physician hand hygiene.[35] Similar to role models is the concept of positive deviance, which refers to a social and behavioral change process based on the premise that in most organizations there are people who solve problems better than colleagues with the exact same resources.[36–38] Positive deviance has been used successfully in several studies to improve healthcare providers' hand hygiene compliance rates.[36,37,39]

Interestingly, we found a difference among specialties with regard to the influence of other team members on hand hygiene practices, indicating that the importance of social influences may vary by specialty. In our study, fewer surgery than medicine physicians stated that other team members influenced their hand hygiene practice. This may be due to sample size but may also be explained by the nature of the work of the 2 specialties investigated in this study. For example, surgeons are required to work more independently than are medicine physicians (who tend to work more in teams); therefore, surgeons may look less on their colleagues for examples of how to practice.

System constraints (environmental context and resources) were consistently and frequently expressed as important barriers and enablers to hand hygiene compliance. A dominant theme across almost all (98%) participants was the importance of easy access to hand hygiene resources at the point of patient contact. This is consistent with previous studies of physician hand hygiene in hospitals generally[2,6] and in specialty (intensive care) units,[36,37] indicating that there may be some behavioral determinants of physician hand hygiene compliance that are common across hospital specialties. High workloads also surfaced as a system constraint in our study. While this is not new,[2,6] we believe that we are among the first to capture this barrier at the individual physician level.

The fact that we were able to identify multiple behavioral determinants to physician hand hygiene compliance suggests that intervention strategies to change this behavior will need to be multifaceted. On the basis of this study, possible actions may include education (eg, disseminating hand hygiene guidelines and evidence linking hand hygiene to healthcare-associated infections), skills development (eg, on hand hygiene technique), motivation (eg, to increase the priority assigned to hand hygiene), and system change (eg, to improve access to hand hygiene resources and incorporation of reminders into daily routines). In addition to these strategies that are known to be effective at changing healthcare provider behavior generally,[40] attempts to reinforce the importance of role modeling and positive deviance strategies should also be considered.

Our study has several strengths. Interviewing residents in addition to staff physicians in 2 specialties (medicine and surgery) provided the perspectives of both key groups responsible for the majority of inpatient medical services in our hospital. Even though the participants interviewed differed in their roles and specialty, their responses around hand hygiene largely converged, indicating similar determinants to the behavior. Further, a systematic and comprehensive approach to data collection and analysis was undertaken, adding to the rigor of the research and trustworthiness of our findings. By using the TDF, which is a compilation of 33 different theories, more possible determinants of the behavior were identified than in previous studies that relied on a single theory. For instance, we identified 53 specific physician hand hygiene beliefs compared with approximately 20 beliefs in the Erasmus[7] qualitative study.

While we provided much needed valuable insight into the factors that may influence physician hand hygiene compliance, there were some limitations. First, while the specific beliefs identified in this study represent physicians' views about what might influence their hand hygiene compliance, they do not provide evidence of the actual influences on physician hand hygiene compliance. Second, we limited key informants to physicians and residents, but other healthcare professionals may also be able to provide valuable insight into physician hand hygiene compliance. Third, it is possible that the key informants participating in the study (who agreed to be interviewed) may differ from those who did not participate with respect to their beliefs and attitudes about hand hygiene. Finally, some of the terms used in the interview guide (eg, guidelines) could be seen as broad. We did not attempt to operationalize these terms; therefore, they were left open to interpretation.

Our next steps involve developing an intervention—tailored to the barriers and enabler identified—to improve physician hand hygiene. The intervention will be pretested in the hospital where the physician key informants were interviewed, and if successful, a larger trial will be planned.

In summary, physician hand hygiene compliance continues to be a major challenge globally. This qualitative study demonstrated the utility in using psychological theories commonly used in knowledge translation and health psychology research to explore the determinants of hand hygiene compliance. The results provide a much-needed and better understanding of physicians' behavior change processes in relation to hand hygiene practice and should be used to inform the design of future intervention strategies to improve this behavior. Future interventions should be multifaceted and account for the knowledge and skills deficits, environmental context issues, as well as individual physician cognitive factors identified.