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infection control and hospital epidemiology february 2010, vol. 31, no. 2
original article
Focus Group Study of Hand Hygiene Practice among Healthcare
Workers in a Teaching Hospital in Toronto, Canada
Ji-Hyun Jang, MHSc; Samantha Wu, BSc; Debra Kirzner, MPH; Christine Moore, ART; Gomana Youssef, MSc;
Agnes Tong, MSc; Jenny Lourenco, MSc; Robyn B. Stewart, BA; Liz J. McCreight; Karen Green, MSc;
Allison McGeer, MD
objective. To understand the behavioral determinants of hand hygiene in our hospital.
design. Qualitative study based on 17 focus groups.
setting. Mount Sinai Hospital, an acute care tertiary hospital affiliated with the University of Toronto.
participants. We recruited 153 healthcare workers (HCWs) representing all major patient care job categories.
methods. Focus group discussions were transcribed verbatim. Thematic analysis was independently conducted by 3 investigators.
results. Participants reported that the realities of their workload (eg, urgent care and interruptions) make complete adherence to hand
hygiene impossible. The guidelines were described as overly conservative, and participants expressed that their judgement is adequate to
determine when to perform hand hygiene. Discussions revealed gaps in knowledge among participants; most participants expressed interest
in more information and education. Participants reported self-protection as the primary reason for the performance of hand hygiene, and
many admitted to prolonged glove use because it gave them a sense of protection. Limited access to hand hygiene products was a source
of frustration, as was confusion related to hospital equipment as potential vehicles for transmission of infection. Participants said that they
noticed other HCWs’ adherence and reported that others HCWs’ hygiene practices influenced their own attitudes andpractices.Inparticular,
HCWs perceive physicians as role models; physicians, however, do not see themselves as such.
conclusions. Our results confirm previous findings that hand hygiene is practiced for personal protection, that limited access to
supplies is a barrier, and that role models and a sense of team effort encourage hand hygiene. Educating HCWs on how to manage workload
with guideline adherence and addressing contaminated hospital equipment may improve compliance.
Infect Control Hosp Epidemiol 2010; 31:144-150
From the Dalla Lana School of Public Health, University of Toronto (J.-H.J., A.M.), and the Department of Microbiology, Mount Sinai Hospital (all
authors), Toronto, Ontario, Canada.
Received May 12, 2009; accepted July 27, 2009; electronically published December 17, 2009.
䉷2009 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2010/3102-0007$15.00. DOI: 10.1086/649792
Adherence to appropriate hand hygiene practices is an im-
portant means of reducing the risk of healthcare-associated
infection.
1-3
Although multimodal programs designed to im-
prove healthcare worker (HCW) hand hygiene adherence
have been shown to be effective,
1,3,4
their effectiveness has
been limited and often difficult to sustain, and adherence to
hand hygiene guidelines in many healthcare facilities remains
suboptimal.
5-10
Although our understanding of the determinants of hand
hygiene behavior is improving, it is clear that much remains
to be learned.
11
In order to better understand the behavioral
determinants of hand hygiene in our hospital, we undertook
a focus group study.
methods
Mount Sinai Hospital in Toronto, Ontario, Canada, is a 472-
bed acute care tertiary hospital affiliated with the University
of Toronto. The Mount Sinai Hospital hand hygiene program
was initiated in 2004 and comprises the placement of alcohol-
based hand rub, staff education, a hand care program, the
placement of posters, participation in research, a formal au-
dit, and feedback. An alcohol-based hand rub dispenser is
mounted just outside each patient room and at 1 location
inside most rooms. Since 2006, staff have received hand hy-
giene training, including participation in simulations, both
at orientation and during mandatory annual infection pre-
vention training.
Focus groups were conducted during the period from
March through June 2008 with 17 cohorts of HCWs from
whom informed consent was obtained (Table 1). Participants
were recruited by means of e-mailed invitations, invitations
issued at staff meetings, and solicitation of volunteers by de-
partment managers. The same facilitator used a semistruc-
tured interview technique to conduct each 60-minute ses-
hand hygiene and healthcare workers 145
table 1. Data on the Members of the 17 Focus Groups on Hand Hygiene at Mount
Sinai Hospital, Toronto, Canada
Type of healthcare workers
a
No. of
participants
Social workers 8
Staff nurses (2 groups) 10, 6
Nurse managers, clinical nurse specialists, and nurse clinicians 6
Medical imaging technologists 10
Medical students at University of Toronto 10
Internal medicine interns and residents 5
Attending physicians (3 groups) 14, 3, 14
Respiratory therapists 8
Service assistants
b
8
Pharmacists and pharmacy technicians 9
Housekeeping staff 7
Physiotherapists and occupational therapists 12
Staff from multiple disciplines in medical-surgical unit for inpatients 13
Infection control practitioners 10
a
All participating healthcare workers were employees of or students or physicians at the Mount
Sinai Hospital of Toronto, except for infection control practitioners, who came from a number
of other area hospitals and were recruited from the Toronto Practitioners of Infection Control.
b
Service assistants are nonregistered staff who work on inpatient units and whose responsibilities
include portering, cleaning, and other patient support.
sion,
12,13
with additional study staff present to record notes. The
topic was introduced with a video on hand hygiene from the
Ontario Ministry of Health and Long-Term Care, which was
followed by a review of definitions and guidelines for hand
hygiene.
14
Initial questions were developed on the basis of a
review of the literature and by consultation with an interna-
tional expert panel. On the basis of the results from 9 focus
groups, the questions were modified to facilitate the exploration
of new themes. The questions asked are available from the
authors on request.
Each focus group meeting was followed by an immediate
debriefing session among the facilitator and study assistant(s).
Audiotapes of the full session were transcribed verbatim, and
transcripts were proofread by a second individual. Thematic
analysis of transcripts was facilitated with the use of NVivo
8 software (QSR). Three individuals (J.-H.J., D.K., and S.W.)
conducted the analysis independently. Each reviewed the oth-
ers’ results, and then they established the final themes by
consensus. The study was approved by the Mount Sinai Hos-
pital research ethics board.
results
Four themes emerged from our analyses (Table 2). In general,
themes were consistent across all groups of HCWs; differences
between occupational groups, if present, are noted. Only 1
substantial disagreement regarding themes was identified in
the 3 independent analyses: 1 investigator felt that the concept
of hospital administration support for hand hygiene should
be a theme rather than a subtheme.
It should be noted that, in most cases (78% of all refer-
ences), participants used the term wash to refer to any method
of cleaning hands, including both use of alcohol hand rub
and use of soap and water. Although more than 90% of hand
cleaning at our hospital is done using alcohol hand rub rather
than soap and water (Mount Sinai Hospital infection control
team, unpublished observations), the term wash persists
among staff.
Theme 1: Adherence to Guidelines Is Compromised by
HCW Knowledge and Beliefs
All groups of HCWs admitted to making compromises that
reduce their adherence to hand hygiene guidelines. Many
HCWs felt that the guidelines did not take into consideration
the reality of daily practice. They believe that guidelines
should be compromised during emergencies and when the
workload is heavy.
Nurse: If you have a chest pain on the floor, we’re going right
away; we’re not going to wash our hands.
Nurse supervisor: We’re talking about nurses… . They don’t
have time.
Radiology technician: We take 4–5 pictures per patient so we
can’t be washing our hands between exposing and going back
and touching the patient.
Frequent interruptions can also cause HCWs to occasion-
ally forget to practice hand hygiene:
Service assistant: When we’re doing something, and the nurse
calls for us, yeah you may not remember to wash.
Some HCWs had insufficient knowledge about hand hy-
giene, for instance, believing that soap and water were more
effective than alcohol hand rub or not recognizing that several
146 infection control and hospital epidemiology february 2010, vol. 31, no. 2
table 2. Identified Themes and Subthemes Describing Factors That Influence Adherence to Hand Hygiene Guide-
lines among Healthcare Workers (HCWs) at the Mount Sinai Hospital, Toronto, Canada
Theme, subtheme Description
Theme 1 Adherence to guidelines is compromised by HCW knowledge and beliefs
Subtheme A Some HCWs do not agree with the guidelines; they believe that the guidelines are unrealistic
and overly conservative
Subtheme B HCWs have gaps in hand hygiene knowledge
Theme 2 Hand hygiene is practiced for personal protection
Subtheme A Risk to self and loved ones is the most important reason for hand hygiene
Subtheme B Gloves give the wearer a false sense of protection
Subtheme C Subjective risk perception is a strong indicator of hand hygiene
Theme 3 The external environment influences hand hygiene behavior
Subtheme A Accessibility of hand hygiene supplies is critical
Subtheme B Contaminated, inanimate objects make hand hygiene adherence challenging
Subtheme C Institutions are not supportive of hand hygiene
Subtheme D Improved technology would support hand hygiene practices
Theme 4 Professional responsibility
Subtheme A With regard to hand hygiene, communication between HCWs should be facilitated
Subtheme B Physicians are unaware that, with regard to hand hygiene, they are role models to other HCWs
Subtheme C Accountability increases hand hygiene adherence
hand hygiene episodes can occur in the course of a single
interaction with a patient.
Physician: I think it is much better to wash with soap and water
if you’re touching patients.
Physiotherapist: I don’t necessarily think that it [hand hygiene]
is necessary if I am just working with the same patient.
Most HCWs expressed a desire for more information about
hand hygiene; however, the type of information desired dif-
fered, depending on the occupation of the HCW. Generally
speaking, professional HCWs wanted surveillance data and
evidence of efficacy, while nonprofessional HCWs wanted
rationale-based instruction. Many groups felt that educational
sessions on hand hygiene should be held more frequently to
regularly remind HCWs about hand hygiene.
Housekeeper: I think the hospital should be providing more
education for hand hygiene because once in a while we need to
review that and refresh ourselves.
Nurse: I noticed whenever they have us doing like a corporate
day, it kind of motivates you for the next couple of days and
you’re all gung ho about washing and doing things and then it
kind of fades.
Theme 2: Hand Hygiene Is Practiced for Personal
Protection
Although participants recognized that hand hygiene needs to
be practiced to protect other HCWs and patients, they also
acknowledged that their main motivation for practicing hand
hygiene was to protect themselves and their loved ones.
Physician: I worry more about myself than the patients, to be
quite honest.
Service assistant: You’re trying to protect yourself from bring-
ing anything home especially if you have little ones.
Pharmacist: It’s just human nature, we don’t want to pick any-
thing up from these sick patients.
A variety of HCWs acknowledged that gloves offer them
a false sense of security. HCWs admitted to wearing the same
pair of gloves for extended periods of time and for multiple
activities because they felt protected.
Medical imaging technologist: You have this sense after a
while that your gloves are giving you a lot of protection so why
do I really need to wash…. I tend to view the gloves as super
protection.
Physician: I don’t wash them [my hands] as a way of hygiene
because I figure I’m using gloves, you know what I mean.
Participants agreed that they routinely differentiate be-
tween high-risk and low-risk patients, between high-risk and
low-risk environments, and between high-risk and low-risk
types of contact. They described being more attentive to hand
hygiene in situations in which there was a perception of “dirt-
iness” or elevated personal risk.
Nurse: Like if you know the patient has hepatitis A or B or HIV
or something like that, we’re just more cautious.
Nurse: If I was walking into a room that’s messy and stuff, it
makes me very uncomfortable.
Physician: And the very clean normal patient, you sort of en-
vision interaction much like you would in normal social
interaction.
Some HCWs who are routinely exposed to wounds or to
body fluids seem to have reframed risk assessment decisions
according to internal frames of reference, such that they may
be desensitized to risk.
Nurse: You have your clean trachs and you have your dirty trachs.
Physician: When you are examining patients, you are not cutting
them open and you are not as reminded to wash your hands all
hand hygiene and healthcare workers 147
the time. I think the only time we promptly do it is if they have
a really nasty wound.
Theme 3: The External Environment Influences Hand
Hygiene Behavior
Participants cited numerous ongoing barriers to hand hy-
giene, most commonly unreliable access to alcohol hand rub,
skin damage caused by frequent performance of hand hy-
giene, and buildup of residual emollients on the hands.
Social worker: A lot of dispensers are empty…and I don’t
necessarily go find another one.
Physiotherapist: If there was some rub right beside the bed,
you’d probably say, “Oh, there it is. I’ll use it.”
HCWs also suggested that the hospital invest in improved
technology, such as hand rub that is less damaging to skin
and hands-free cellular phones.
Nurse: At a couple hospitals…you have like a little locator on
you, and when you go into a room there’s a thing that shows
where you are so they can just call into that room through the
call-bell-type system.
Members from all focus groups discussed their frustration
with the sources of transmission of microorganisms in the
hospital other than the hands of HCWs. There was a wide
variety of opinion about the importance of environmental
surfaces in the transmission of microorganisms, with some
HCWs believing that the patient environment was unim-
portant and other HCWs believing it to be of real concern.
Physician: Because honestly, I don’t think I necessarily agreethat
touching a chair means I need to wash my hands or else I would
be washing my hands constantly.
Nurse leader: You can see where there’s a risk going from patient
[to] patient…but not necessarily going from patient to bedside
table or from bedside to patient. The theory behind that is a little
obscure.
Physiotherapist: It’s the equipment…. Nurses, after they use
the pulsimeters [sic] or blood pressure cuff or whatever, it’s never
wiped off.
Many participants cited frustration with the handling of
the equipment that is carried from patient to patient: they
perceive that this equipment is not cleaned or is difficult to
clean between patient visits and that it is hard to know when
to clean hands when they are moving back and forth between
a patient and the piece of equipment. Numerous focus groups
discussed their feelings of futility about performing hand
hygiene when the cleaning of these objects is inadequately
addressed.
Nurse: So, you can wash hands until you’re blue in the face; the
equipment is still going to carry it around.
Nurse: Well even if you clean your hands, there are those filthy
drapes.
Many participants also expressed frustration with what they
perceived as a risk of transmission associated with patients
and visitors.
Service assistant: Sometimes you see family members going
inside and we have to wear all of that stuff, and sometimes they
come out, they sit down, watch TV…
Physiotherapist: Even when they [visitors] are in isolation
rooms, they’ll go to the pantry, they’ll come back, they’ll touch
stuff.
The lack of hospital initiatives that address sources of trans-
mission other than the hands of HCWs was just one of the
areas participants cited in which the hospital could provide
better support for hand hygiene. Other examples included
more education and the purchase of more medical supplies
to facilitate work flow and reduce the number of hand hygiene
opportunities.
Theme 4: Professional Responsibility
All participants reported that they noticed other workers’
hand hygiene practices. All nonphysician participant groups
discussed physician practice in particular, with 9 of 13 groups
concluding that physicians had the poorest practice. Physi-
cians, in contrast, rarely reported that they noticed the hand
hygiene practices of other HCWs but did report that they
noticed the behavior of more senior physicians. Medical stu-
dents described the strong influence that physicians’ hand
hygiene practices had on their own practice, noting that poor
hand hygiene by senior physicians negatively influenced their
own. The physician groups did not agree that they were role
models to other staff, although they did agree that senior
physicians were role models to junior physicians and medical
students. Participants other than medical students stated that
witnessing poor hand hygiene practice did not negatively af-
fect their own hand hygiene practice, but they still found it
discouraging.
Physiotherapist: I think sometimes it makes you question
what’s the point if you are seeing people going in, not washing
their hands, touching things…it is frustrating.
At the same time, they also reported that seeing others set
a good example was encouraging.
Physiotherapist: I find when people are washing their hands,
it triggers me to wash my hands more.
While 6 of the 17 groups stated that there should be a
work environment in which it would be acceptable to remind
and encourage others to clean their hands, few participants
reported feeling comfortable reminding others, and partici-
pants in 8 groups reported upsetting experiences when trying
to do so. Nurses expressed frustration in communicating with
certain physicians, and some professional groups, notably res-
piratory therapists, expressed frustration in communicating
with service assistants and housekeeping staff. Several groups
emphasized the importance of team effort in achieving good
hand hygiene practice.
148 infection control and hospital epidemiology february 2010, vol. 31, no. 2
Pharmacist: I do think it [practicing good hand hygiene] will
become a lot easier when we see other people, everyone’s doing
it…if nurses were to do that all the time, physicians were to do
that all the time, I think I would pick up on habits more.
Some groups mentioned deliberately practicing hand hy-
giene in front of patients and visitors to reassure them. Others
mentioned that they would feel ashamed if a patient asked
whether they had cleaned their hands when they had not.
Pharmacist: If a patient asks you, “did you wash your hands”
and you say no, you’ll be washing your hands for the rest of the
day because that’s pretty humiliating.
Participants also reported that they took hand hygiene au-
dits seriously, commenting that auditing reminded them
about hand hygiene. Participants from 8 focus groups ex-
plicitly viewed audits as a way of being held accountable, with
the belief that personalized feedback was particularly effective.
Physician: And everybody needs to be audited on some things.
Most of us fill out our tax forms honestly but it helps to know
that 1 person in a 100 gets audited. It’s human nature if you
know there’s an occasional radar trap in your neighborhood,
you’re going to be more careful about the speed limit…. So it’s
good to be audited.
discussion
Despite a World Health Organization campaign, new accred-
itation guidelines, and a provincial strategy for hand hygiene,
adherence to hand hygiene remains suboptimal in our hos-
pital and in many others in Ontario.
5-10
Our study identifies
a number of reasons why this is occurring and provides some
insight into how hand hygiene programs can be improved.
Many HCWs in our study described the current hand hy-
giene guidelines as unrealistic. Some, particularly physicians,
do not believe that the evidence base supporting hand hygiene
guidelines is sufficient; others see that, given current work-
loads, other patient care needs should be prioritized over
hand hygiene. These findings are consistent with those of
previous studies that reported reduced hand hygiene adher-
ence in association with increasing workload
15,16
and with the
findings of studies that documented increased hand hygiene
adherence in association with a positive attitude toward hand
hygiene.
15
Convincing physicians of the adequacy of the data
supporting hand hygiene may be particularly important, since
all other HCWs view physicians as role models. For other
HCWs, analysis and redesign of work flow may be needed
to reduce the frequency of hand hygiene opportunities.
17
Our participants clearly cited personal safety as the primary
reason for hand hygiene practice. These results are consistent
with findings of significantly higher hand hygiene adherence
after rather than before patient contact,
9,10,18
and they con-
tribute to our understanding of other behaviors, such as glove
use. Participants were also confident in their abilities to dis-
cern high- and low-risk situations, using their own judgment
rather than the recommendations of guidelines. Previous
studies demonstrated that HCWs use their own assessment
of risk rather than the recommendations of guidelines when
dealing with precautionary measures to prevent the spread
of infectious respiratory diseases
19,20
and bloodborne patho-
gens.
21
This reliance on subjective risk assessments is of par-
ticular concern, because our results also reveal that routine
exposure to high-risk situations can desensitize HCWs, so
hand hygiene may become elective in situations that were
previously perceived to be high risk.
19,22
Our results also reinforce the accuracy of the classification
by Whitby et al of hand hygiene practice into “elective” and
“inherent”
11,23
and the finding by Curtis et al that disgust is
an important motivation for hand hygiene.
24,25
Participants
uniformly reported being more vigilant about hand hygiene
in situations considered to be either physically dirty or “emo-
tionally dirty,” that is, moments that Whitby et al
11,23
de-
scribed as inherent. Our participants also included contact
with some patients (eg, those infected with human immu-
nodeficiency virus or colonized by vancomycin-resistant En-
terococcus) in the same category of concern, which suggests
that patients with some infectious diseases are also seen as
“dirty,” and this perhaps provides a reason why patients iden-
tified as requiring additional precautions may receive lower
quality care.
26
These results, as well as the fact that some
HCWs admit to feeling safe while wearing gloves for pro-
longed periods of time while at the same time realizing that
the sense of security is false, emphasize the extent to which
both disgust with perceived contamination and social ac-
ceptability affect hand hygiene habits.
Confusion and frustration about the relative contribution
of HCW hands and the inanimate environment to trans-
mission of pathogens, as well as the perceived inadequacy of
environmental cleaning, permeated discussions in many of
our groups. Many studies have documented the contami-
nation of the environment of patients and of equipment that
moves from patient to patient.
27-30
These discussions empha-
size the need for hand hygiene guidelines to include an ex-
plicit discussion about how to decide on appropriate hand
hygiene in circumstances in which the hands of a HCW move
back and forth between the equipment and the patient re-
peatedly, and about how to disinfect mobile equipment (eg,
stethoscopes), as well as hands, between patient visits.
Various aspects of professionalism, particularly commu-
nication, collaboration, and accountability, also influence
HCWs’ hand hygiene practices. Study participants frequently
commented that hand hygiene is a team effort and that open
communication, in which respectful hand hygiene reminders
are welcomed, would facilitate hand hygiene adherence. Cur-
rently, HCWs feel uncomfortable reminding each other about
hand hygiene. Our results also emphasize the important effect
of role models, particularly senior medical staff, as previously
demonstrated by several studies.
23,31-33
The adherence of phy-
sicians to hand hygiene guidelines would be particularly ben-
eficial to the success of hospital hand hygiene programs.
hand hygiene and healthcare workers 149
Our study has several limitations. Similar to those of other
focus groups, our participants were a group of volunteers
recruited through mixed, purposeful sampling; hence, readers
should be cautious about generalizing the views expressed by
participants in our study to staff in other hospitals or health-
care settings. Some participants may not have been com-
pletely honest in their discussions, particularly because some
focus groups were composed of HCWs with varying levels of
training and seniority. As in any focus group study, we do
not know to what extent the participants’ views reflect the
reality of the situation. Despite these limitations, the inclusion
of participants from a wide variety of healthcare occupations
and with different levels of training (with sampling to sat-
uration) and the use of independent thematic analysis suggest
that our findings are valid.
In conclusion, the results of this qualitative study suggest
a number of ways that hand hygiene programs can be sup-
ported and improved. Participants emphasized the need for
a continued focus on the removal of practical and logistical
barriers to good practice, on the need to convince senior
medical staff to become role models for adherence, and on
the need for profession-specific ongoing education and feed-
back about practice. Research that contributes to a clear un-
derstanding of the relative contributions of environmental
contamination and hand contamination to pathogen trans-
mission in the hospital is clearly needed; in its absence, hand
hygiene programs may be best supported by programs that
ensure regular disinfection of patient care equipment and by
a focus on understanding how to interpret hand hygiene
guidelines when complex and mobile patient-care equipment
is used.
acknowledgments
We are grateful to the many staff members who participated in these focus
groups, to the department managers and other staff who supported thestudy
by assisting in recruitment, and to the Canadian Institutes for Health Re-
search (grant PHE 78706), the Canadian Patient Safety Institute, and the
Ontario Ministry of Health, who provided funding for this study through a
Partnerships in Health System Improvement grant. We also thank the project
advisory committee for their valuable advice: Chantal Backman, Clare Barry,
Elizabeth Bryce, Daniel Carriere, Paula Greco, Karen Hope, Joanne Laalo,
Elaine Larsen, Lianne MacDonald, Shirley Paton, Didier Pittet, Hugo Sax,
Gilad Shohan, and John Wellner.
Potential conflicts of interest. All authors report no conflicts of interest
relevant to this article.
Address reprint requests to Allison McGeer, MD, Department of Micro-
biology, Room 210, Mount Sinai Hospital, 600 University Avenue, Toronto,
ON M5G 1X5, Canada (amcgeer@mtsinai.on.ca).
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