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Hand hygiene adherence is influenced by the behavior of role

James Schneider, MD; David Moromisato, MD; Beth Zemetra, RN; Lisa Rizzi-Wagner, RN;
Niurka Rivero, MD; Wilbert Mason, MD; Flerida Imperial-Perez, RN; Lawrence Ross, MD

Objective: Proper hand hygiene (HH) reduces nosocomial in- nities, and improved to 56% of 234 opportunities as a result of
fections. Therefore, factors that influence HH behavior of health- role modeling—an average increase of 34% points (95% con-
care workers are of great interest. We hypothesized that strict HH fidence interval, 18.7–51; p < 0.01 by linear regression),
adherence by supervisor role models would improve the HH representing a HH adherence rate greater than 1.5 times that of
behavior of junior staff. the baseline. The control senior practitioners’ HH adherence
Design: Prospective observational study. rate was 20% of 180 opportunities compared with the study
Setting: Pediatric and cardiac intensive care units of a tertiary senior practitioners’ HH adherence of 94% of 187 opportuni-
care children’s hospital. ties—an average difference of 72% points higher compared
Subjects: Two critical care fellows and four nurse orientees. with the control senior practitioners (95% confidence interval,
Interventions: First, we observed and recorded HH adherence 56 – 88.3; p < 0.01 by linear regression).
of the fellows and nurse orientees and their respective supervis- Conclusions: HH adherence of junior practitioners improved
ing attending physician or nurse preceptor during daily patient under the supervision of adherent role models. These results
care. Subsequently, we paired the same fellows and nurse orien- suggest that HH behavior of senior practitioners plays a crucial
tees with a different supervisor who maintained strict HH adher- influence on other staff. Senior healthcare practitioners should
ence, and again noted HH adherence. We used measures of HH consider the important role they may play in reinforcing or weak-
opportunities and HH adherence consistent with guidelines set by ening a culture of patient safety and proper HH. (Pediatr Crit Care
the Centers for Disease Control and Prevention and Association Med 2009; 10:360 –363)
for Professionals in Infection Control and Epidemiology. KEY WORDS: role; handwashing; infection control; nosocomial
Measurements and Main Results: HH adherence by fellows infections; behavior; health personnel
and nurse orientees at baseline was 22% of 200 HH opportu-

H ospital-acquired infections In a seminal observational study by that handwashing prevents nosocomial

affect 5% to 10% of all hos- Semmelweis over 150 years ago, mater- infections, personal commitment to
pitalized patients and are nal mortality because of puerperal fever handwashing, easy access to hand-rub so-
the most common cause of was reduced from 22% to 2% as a result lution, and knowledge of being part of a
preventable morbidity and mortality fac- of handwashing between performing nec- study (5, 18, 19). Behavioral change has
ing health care today (1). It is estimated ropsies and newborn deliveries (4). De- undergone extensive investigation, re-
that 30% of hospital-acquired infections spite the current clear evidence and wide- sulting in various ideas of what influ-
are avoidable with healthcare provider spread acceptance that healthcare ences change. Unfortunately, handwash-
adherence to hand hygiene (HH) guide- provider adherence with handwashing is ing adherence in daily work routines has
lines (2), thus preventing patient-to- the cornerstone of effective infection con- not improved with implementation of
patient and healthcare worker-to-patient trol, rates of adherence observed in nu- these theories (7, 9, 13).
transmission of microorganisms that merous studies are disappointing (1, The use of role models or mentors to
cause most nosocomial infections (3). 4 –10). HH adherence among healthcare influence behavior has been suggested in
providers ranges from 5% to 81%, with the past. Role models in medical educa-
an overall average of 40% (1). Physician tion influence the knowledge, skills, and
From the Department of Anesthesiology Critical adherence is commonly inferior to that of values that are brought to the bedside,
Care Medicine (JS, DM, BZ, LR-W, NR, FI-P); Division nurses (6). Previous studies attempting and play a significant influence on the
of Infectious Diseases (WM, LR); Department of Pedi-
atric Critical Care Medicine (JS), Childrens Hospital Los
to improve HH behavior of healthcare career choices made by graduating med-
Angeles, Los Angeles, CA. workers have been unable to sustain suc- ical students (20). Few studies have ex-
The authors have not disclosed any potential con- cess in improving infection control prac- amined the impact of role modeling by
flicts of interest. tices (6 – 8, 11–17). A multidisciplinary, senior physicians and nurses on the HH
For information regarding this article, E-mail:
hospital-wide program promoting HH behavior of their junior colleagues (1, 5).
Copyright © 2009 by the Society of Critical Care has been the most effective means of im- It has been suggested that the effect of
Medicine and the World Federation of Pediatric Inten- proving HH practice (8). Factors identi- the role model is highly significant, but
sive and Critical Care Societies fied as having positive influences on most potent in negatively influencing
DOI: 10.1097/PCC.0b013e3181a32f16 handwashing adherence are knowledge hand hygiene behavior (12). In a large

360 Pediatr Crit Care Med 2009 Vol. 10, No. 3

cross-sectional survey, the belief of being
a role model for other colleagues posi- 100 94 *
tively influenced the behavior of the phy-
sicians involved (19). In this study, we

% Adherence
examined the effect of attending physi-
60 56 *
cians’ and senior nurses’ HH behavior on
their junior colleagues’ adherence to ap-
propriate HH. We hypothesized that HH 40

adherence of junior healthcare providers 22 20

will improve in the presence of senior 20

practitioners who model appropriate HH.

MD/RN Role Model MD/RN Role Model
Control Period Study Period
From September 2006 to January 2007, we
studied HH adherence of physicians and Figure 1. Hand hygiene adherence rates for critical care fellows (MD) and nurse graduates (RN) as well
nurses providing patient care in the pediatric as respective attending physicians and senior nurses (role model) at baseline and under the influence
intensive care unit and cardiothoracic inten- of study role models. *p ⬍ 0.01 compared with baseline.
sive care unit at a tertiary care children’s hos-
pital in Los Angeles. Each patient room in 100
each intensive care unit (ICU) is well
equipped with soap and sinks as well as 80

% Adherence
antiseptic alcohol gel (Avagard D, 61% eth-
anol, 1% chlorhexidine gluconate; 3M 60
Healthcare, St. Paul, MN).
Two critical care fellows and four nurse 40
orientees were studied. First, in an unobtru-
sive manner, the unidentified observer re- 20
corded HH adherence of the fellows and nurse
orientees and their respective supervising at- 0
tending physician or nurse preceptor during Control Period Study Period
multiple 2-hour time periods during daily pa-
tient rounds and routine care. In the subse- Figure 2. Change in hand hygiene adherence of individual junior healthcare workers after the
quent study period, we paired the same fellows influence of adherent role models. Five of the six junior practitioners improved hand hygiene
adherence under the supervision of the more adherent supervising senior practitioners.
and nurse orientees with a different supervisor
who was asked by the investigator before the
observation period to maintain strict HH ad-
herence. Further, the second group of attend- Standardized forms containing the Centers higher compared with the control senior
ing physicians and nurse preceptors were in- of Disease Control and Prevention and Associ- practitioners (95% confidence interval,
structed not to give their respective trainees ation of Professionals in Infection Control and 56 – 88.3; p ⬍ 0.01). Concomitantly, the
any other cues or reminders regarding the Epidemiology definitions of HH opportunities, fellows’ and nurse orientees’ adherence
adherence of accepted HH. Again, HH adher- patient contacts, and invasive procedures were improved to 56% of 234 opportunities
ence was noted for this new group of senior used for data collection. Data were then pro- under the supervision of the study role
healthcare workers as well as the original jun- cessed and analyzed using the STATA statistical models (Fig. 1). This was an average in-
ior trainees. All HH opportunities were re- software (version 9.0, Stata, College Station, crease of 34% points (95% confidence
TX). Linear regression was used to evaluate the
corded during these observation periods, both interval, 18.7–51; p ⬍ 0.01), representing
in the presence and absence of the senior role interaction between the difference in HH adher-
a HH adherence rate greater than 1.5
models. Other than the study group of attend- ence rates of the senior healthcare workers and
times that of the baseline. Five of the six
ing physicians and nurse preceptors, the ob- that of the critical care fellows and nurse train-
ees. A p value of less than 0.05 was considered
junior practitioners had a significant im-
served healthcare workers were unaware of provement over baseline (␹2, p ⬍ 0.01)
the study taking place. The study was approved statistically significant.
whereas the sixth had no association (p ⫽
by the hospital’s institutional review board. 0.88) (Fig. 2).
HH was defined as 1) handwashing with RESULTS
soap and water with a minimum of 15 seconds
HH adherence by the control senior DISCUSSION
scrubbing before rinsing or 2) use of Avagard
D antiseptic gel applied to and rubbed into all
practitioners was 20% of 180 HH oppor-
hand surfaces until dry. The definitions of tunities. During the same baseline study In our study, HH adherence signifi-
hand hygiene opportunities, invasive proce- period, the adherence rates of the critical cantly improved among the junior
dures, and patient contact used for the study care fellows and nurse orientees was 22% healthcare team members in the pres-
are consistent with the guidelines set by the of 200 HH opportunities. With the verbal ence of senior providers who modeled
Centers of Disease Control and Prevention and reminder from the investigator and appropriate behavior. Although super-
the Association of Professionals in Infection knowledge of being observed, the study vised by senior physicians and nurses
Control and Epidemiology (1). Any HH oppor- group of senior practitioners’ HH adher- who averaged 20% adherence, the junior
tunity that did not completely adhere to these ence was 94% of 187 opportunities. This staff demonstrated an adherence rate of
definitions was considered a failed attempt. was an average difference of 74% points only 22%. Subsequently, under the su-

Pediatr Crit Care Med 2009 Vol. 10, No. 3 361

pervision of senior physicians or nurses with improved HH practice involved a hos- under the supervision of other senior
whose HH adherence averaged 94%, our pital-wide program of poster campaigns physicians and nurses. Finally, while we
study group of juniors improved their and introduction of alcohol handrubs. As a noticed a significant improvement in the
practice, increasing their average adher- result, the institution’s nosocomial infec- HH behavior of the junior practitioners
ence to 56%. Specifically, five of the six tion rate declined from 16.9% to 9.9% in a during the study, none of the trainees’
observed junior healthcare providers sig- 4-year period (8). HH adherence matched their respective
nificantly improved. These results sug- Eliminating physical barriers and im- study role models and one of our junior
gest role modeling is an important factor proving accessibility to handwashing may trainee’s behavior did not change at all
for improving HH behavior at the bed- be influential for improving HH rates (7), despite the presence of an adherent role
side. but the most compelling factors deter- model. Thus it is apparent other factors
Numerous studies have revealed unac- mining adherence may be the behaviors not measured in our study influenced the
ceptably low rates of handwashing adher- of senior healthcare workers. It has been behavior of the junior practitioners, such
ence by healthcare workers (7, 8, 11, 14), stated, “The failure of healthcare workers as clinical workload and personal motiva-
particularly in ICUs (10, 21–23), from as to decontaminate their hands reflects the tion toward HH. Nevertheless, even with
low as 4% in an adult cardiac surgery ICU fundamentals of attitudes, beliefs, and be- the limitations of the current study, our
(7) to as high as 81% in an adult ICU (16). haviors.” (4) Indeed, these fundamentals results suggest the senior role model
It is estimated that adherence rates constitute the environment, or culture, plays an important role in HH adherence.
across the country are less than 50% (3). in which young physicians and nurses
Clinical factors that have been corre- learn and develop. Role models inspire by CONCLUSION
lated with adherence to HH include being their own conduct (20) and play an es-
a respiratory therapist, working in a neo- sential role in medical education. Lank- The results of our study suggest the
natal ICU, low patient-to-nurse ratios, ford et al (12) demonstrated that health- behavior of senior physicians and nurses
and contact with wounds, body fluids, or care workers are less likely to wash their plays an important role on the handwash-
invasive devices (14, 17). hands in the presence of a senior medical ing behavior of junior staff they super-
Previous studies have identified sev- staff person who did not wash his/her vise. In addition, the results also suggest
eral factors that appear to interfere with hands. Healthcare professionals too often that other factors not measured in the
proper HH. Adherence appears to suffer do not think of themselves as role mod- current observation influences the behav-
in hospital settings requiring high levels els, underestimating the impact their be- ior of these practitioners. Thus, HH be-
of patient care, as in ICUs (6 – 8). Self- havior has on the culture, and ultimately, havior appears to involve a complex in-
reported surveys have identified skin ir- on the behavior of those they interact teraction of culture and science, and our
ritation, inaccessible handwashing sup- with. Yet, despite current recommenda- results suggest that further investigation
plies, thinking that wearing gloves is tions for targeting role models as an es- of the impact of mentors and teachers in
adequate, “being too busy,” interference sential agent for improving HH practices this area of care would prove worthwhile.
with healthcare worker relationships (1, 28) our study is the first to confirm The small size of this study aside, we
with patients, skepticism regarding the this importance. Although our results believe senior healthcare practitioners
value of HH, “not thinking about it,” or demonstrate appropriate role modeling is should consider the important role they
lack of knowledge of guidelines as rea- essential, our mean HH adherence rate of may play in reinforcing or weakening a
sons cited for poor HH practices (12, 13, 56% among junior staff is still far from culture of patient safety and proper HH.
15, 16). acceptable, suggesting that other factors
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