Logo: to the web site of Uppsala University

Healthcare-associated infections (HAI) are a problem in health care worldwide. In Sweden 7-8% of all patients treated in hospital suffer from an adverse event of varying severity, of which approximately 60,000 from a HAI. Proper hand hygiene is considered the single most important measure to reduce HAI. Despite the importance, adherence to correct hand hygiene routines are lacking among healthcare workers (HCWs). The World Health Organizations (WHO) multimodal promotion strategy promotes areas that need to be addressed in order to change the behaviour of individual HCWs to optimise adherence to hand hygiene and to improve patient safety. These areas include feedback, education, reminders at the workplace and institutional safety climate. 

The overall aim of this study was to examine the possibility of adherence to hand hygiene routines and to explore factors that might influence the HCWs adherence. 

The study used a descriptive research design made through qualitative method, with focus group interviews, and quantitative method, using a questionnaire survey. Eight focus group interviews were conducted with assistant nurses (n=18), nurses (n=15) and physicians (n=5) and analysed with abductive qualitative content analysis. The questionnaire survey was answered by nurses (n=84) and nursing students in their first semester (n=71) and last semester (n=46) and the data was statistically analysed.

The main findings show that there are barriers to hand hygiene adherence and measures to improve these. HCWs highlighted discrepancies regarding how the organisation was supposed to give feedback and how it actually was at the workplace and expressed needs for more direct feedback to improve adherence. The study also found that hygienic knowledge gaps exists among nurses and nursing students regarding causes of HAI and how the risk of contamination of patients and HCWs can be minimized among others. Students at the beginning of the education had a lower level of knowledge than last semester students and registered nurses. The last semester students tended to have the highest level of hand hygiene knowledge. 

In conclusion, the key areas presented by WHO’s multimodal promotion strategy to improve adherence all lack the appropriate measures, in some extent. The use of an electronic reminder system could give the means to improve a behaviour as long as the individual integrity is protected and development of curriculums for nursing students and continuing education of nurses is needed to further develop and maintaining knowledge.

Background: Healthcare-associated infections remain a major patient safety concern, and hand hygiene is central to their prevention. Adherence to hand hygiene recommendations remains inconsistent and is influenced by individual and contextual factors. Aim: To investigate factors influencing hand hygiene behaviour among healthcare workers and nursing students. Methods: The thesis comprised one qualitative descriptive study and three quantitative comparative survey studies conducted at a Swedish university and university hospital. Study I involved focus group interviews with 38 healthcare workers. Studies II and III surveyed the same sample of 201 first- and final-semester nursing students and registered nurses using World Health Organization hand hygiene instruments. Study IV compared survey data from independent samples of first- and final-semester nursing students and registered nurses collected during the peak of the COVID-19 pandemic in 2020–2021 and in the post-pandemic period in 2023. Results: Healthcare workers perceived infection prevention information as accessible but reported limited direct feedback on hand hygiene performance. An electronic reminder system was generally accepted when privacy was protected and feedback was provided at group level. Hand hygiene knowledge was moderate to good, but first-semester students had lower scores than final-semester students and registered nurses, and knowledge gaps remained across all groups. Attitudes towards and perceptions of hand hygiene differed between nursing students and registered nurses. Total knowledge scores did not differ significantly between 2020 and 2023, whereas the perceived importance and prioritisation of hand hygiene were lower in 2023. Conclusion: Factors influencing hand hygiene behaviour reflect an interplay between knowledge, perceptions, experience, social influences and institutional conditions. Sustaining hand hygiene as a patient safety priority requires continuing education, constructive feedback, professional role modelling and organisational reinforcement.