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A Qualitative Exploration of Reasons for Poor Hand Hygiene Among Hospital Workers Lack of Positive Role Models and of Convincing Evidence That Hand Hygiene Prevents Cross-Infection

  • V. Erasmus (a1), W. Brouwer (a1), E. F. van Beeck (a1), A. Oenema (a1), T. J. Daha, J. H. Richardus (a1), M. C. Vos (a2) and J. Brug (a3)...

To study potential determinants of hand hygiene compliance among healthcare workers in the hospital setting.


A qualitative study based on structured-interview guidelines, consisting of 9 focus group interviews involving 58 persons and 7 individual interviews. Interview transcripts were subjected to content analysis.


Intensive care units and surgical departments of 5 hospitals of varying size in the Netherlands.


A total of 65 nurses, attending physicians, medical residents, and medical students.


Nurses and medical students expressed the importance of hand hygiene for preventing of cross-infection among patients and themselves. Physicians expressed the importance of hand hygiene for self-protection, but they perceived that there is a lack of evidence that handwashing is effective in preventing cross-infection. All participants stated that personal beliefs about the efficacy of hand hygiene and examples and norms provided by senior hospital staff are of major importance for hand hygiene compliance. They further reported that hand hygiene is most often performed after tasks that they perceive to be dirty, and personal protection appeared to be more important for compliance that patient safety. Medical students explicitly mentioned that they copy the behavior of their superiors, which often leads to noncompliance during clinical practice. Physicians mentioned that their noncompliance arises from their belief that the evidence supporting the effectiveness of hand hygiene for prevention of hospital-acquired infections is not strong.


The results indicate that beliefs about the importance of self-protection are the main reasons for performing hand hygiene. A lack of positive role models and social norms may hinder compliance.

Corresponding author
Department of Public Health, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, the Netherlands (
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1.Donaldson, L. Dirty hands…the human cost. London, United Kingdom: UK Department of Public Health; 2006.
2.Group, HL. Hand washing. BMJ 1999;318:686.
3.Teare, L, Cookson, B, Stone, S. Hand hygiene. BMJ 2001;323:411412.
4.Stone, S, Teare, L, Cookson, B. Guiding hands of our teachers. Hand-.hygiene Liaison Group. Lancet 2001;357:479480.
5.Pittet, D, Allegranzi, B, Sax, H, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641652.
6.World Alliance for Patient Safety. Global patient safety challenge 2005-2006: clean care is safer care. Geneva, Switzerland: World Health Organization; 2005.
7.Day, M. Chief medical officer names hand hygiene and organ donation as public health priorities. BMJ 2007;335:113.
8.Jumaa, PA. Hand hygiene: simple and complex. Int J Infect Dis 2005;9:314.
9.Naikoba, S, Hayward, A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers-a systematic review. J Hosp Infect 2001;47:173180.
10.Larson, EL, Bryan, JL, Adler, LM, Blane, C. A multifaceted approach to changing handwashing behavior. Am J Infect Control 1997;25:310.
11.Pittet, D, Mourouga, P, Perneger, TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999;130:126130.
12.Whitby, M, McLaws, ML, Ross, MW. Why healthcare workers don't wash their hands: a behavioral explanation. Infect Control Hosp Epidemiol 2006;27:484492.
13.Morgan, DL. Focus groups as qualitative research. 2nd ed. London, United Kingdom: Sage; 1997.
14.Patton, MQ. Qualitative research and evaluation methods. 3rd ed. London, United Kingdom: Sage; 2002.
15.Bartholomew, LK, Parcel, GS, Kok, G, Gottlieb, NH. Planning health promotion programs; an intervention mapping approach. San Francisco, CA: Jossey-Bass; 2006.
16.O'Boyle, CA, Henly, SJ, Larson, E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control 2001;29:352360.
17.Creedon, SA. Healthcare workers' hand decontamination practices: compliance with recommended guidelines. J Adv Nurs 2005;51:208216.
18.Lipsett, PA, Swoboda, SM. Handwashing compliance depends on professional status. Surg Infect (Larchmt) 2001;2:241245.
19.Pittet, D, Hugonnet, S, Harbath, S. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene (published correction appears in Lancet 2000;356:2196). Lancet 2000;356:13071312.
20.Feather, A, Stone, SP, Wessier, A, Boursicot, KA, Pratt, C. ‘Now please wash your hands’: the handwashing behaviour of final MBBS candidates. J Hosp Infect 2000;45:6264.
21.Ajzen, I. The theory of planned behavior. Organ Behav Hum Dec Processes 1991;50:179211.
22.Duggan, JM, Hensley, S, Khuder, S, Papadimos, TJ, Jacobs, L. Inverse correlation between level of professional education and rate of handwashing compliance in a teaching hospital. Infect Control Hosp Epidemiol 2008;29:534538.
23.Aragon, D, Sole, ML, Brown, S. Outcomes of an infection prevention project focusing on hand hygiene and isolation practices. AACN Clin Issues 2005;16:121132.
24.Golan, Y, Doron, S, Griffith, J, et al. The impact of gown-use requirement on hand hygiene compliance. Clin Infect Dis 2006;42:370376.
25.Lankford, MG, Zembower, TR, Trick, WE, Hacek, DM, Noskin, GA, Peterson, LR. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis 2003;9:217223.
26.MacDonald, A, Dinah, F, MacKenzie, D, Wilson, A. Performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by MRSA and antibiotic costs. J Hosp Infect 2004;56:5663.
27.O'Boyle, CA, Henly, SJ, Duckett, LJ. Nurses' motivation to wash their hands: a standardized measurement approach. Appi Nurs Res 2001;14:136145.
28.Pittet, D, Simon, A, Hugonnet, S, Pessoa-Silva, CL, Sauvan, V, Perneger, TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004;141:18.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
  • URL: /core/journals/infection-control-and-hospital-epidemiology
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