Journal of Hospital Infection 91 (2015) 59e67 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Psychosocial determinants of self-reported hand hygiene behaviour: a survey comparing physicians and nurses in intensive care units T. von Lengerke a, *, B. Lutze a, K. Graf b, C. Krauth c, K. Lange a, L. Schwadtke b, J. Stahmeyer c, I.F. Chaberny b a
Medical Psychology Unit, Hannover Medical School, Hannover, Lower Saxony, Germany Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Lower Saxony, Germany c Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Lower Saxony, Germany b
A R T I C L E
I N F O
Article history: Received 30 July 2014 Accepted 9 April 2015 Available online 9 June 2015 Keywords: Hand hygiene compliance Intensive care personnel Nosocomial infection prevention Self-regulation Social work environment
S U M M A R Y
Background: Research applying psychological behaviour change theories to hand hygiene compliance is scarce, especially for physicians. Aim: To identify psychosocial determinants of self-reported hand hygiene behaviour (HHB) of physicians and nurses in intensive care units (ICUs). Methods: A cross-sectional survey using a self-administered questionnaire that applied concepts from the Health Action Process Approach on hygienic hand disinfection was conducted in 10 ICUs and two haematopoietic stem cell transplantation units at Hannover Medical School, Germany. Self-reported compliance was operationalized as always disinfecting one’s hands when given tasks associated with risk of infection. Using seven-point Likert scales, behavioural planning, maintenance self-efficacy and action control were assessed as psychological factors, and personnel and material resources, organizational problems and cooperation on the ward were assessed as perceived environmental factors. Multiple logistic regression analysis was employed. Findings: In total, 307 physicians and 348 nurses participated in this study (response rates 70.9% and 63.4%, respectively). Self-reported compliance did not differ between the groups (72.4% vs 69.4%, P ¼ 0.405). While nurses reported stronger planning, self-efficacy and action control, physicians indicated better personnel resources and cooperation on the ward (P < 0.02). Self-efficacy [odds ratio (OR) 1.4, P ¼ 0.041], action control (OR 1.8, P < 0.001) and cooperation on the ward (OR 1.5, P ¼ 0.036) were positively associated with HHB among physicians, but only action control was positively associated with HHB among nurses (OR 1.6, P < 0.001). Conclusion: The associations between action control (self-regulatory strategies where behaviour is evaluated continuously and automatically against guidelines) and compliance
* Corresponding author. Address: Medical Psychology Unit, Hannover Medical School, Carl-Neuberg-Str. 1 (OE 5430), 30625 Hannover, Germany. Tel.: þ 49 (0)511 532 4445; fax: þ 49 (0)511 532 4214. E-mail address: [email protected] (T. von Lengerke). http://dx.doi.org/10.1016/j.jhin.2015.04.018 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
60
T. von Lengerke et al. / Journal of Hospital Infection 91 (2015) 59e67 indicate that HHB is a habit in need of self-monitoring. The fact that perceived cooperation on the ward was the only environmental correlate of HHB among physicians stresses the importance of team-directed interventions. ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction Hand hygiene compliance is generally lower in physicians than in nurses, and physicians do not respond as well to multimodal interventions.1e3 A report from Australia found that compliance followed an inverted U-shaped pattern around the 2006e2007 ‘Clean Hands Save Lives’ campaign, especially in physicians.2 Comparable trends were observed in intensive care units (ICUs) at Hannover Medical School (MHH), Germany.4 During the German ‘Clean Care is Safer Care’ campaign,5 hygienic hand disinfection compliance of physicians was highest in 2011 at 64%, up from 53% in 2008 (pre-campaign) and dropping to 48% in 2013. Among nurses, this trend was 57% (2008), 71% (2009/10) and 56% (2013). Data for other medical specialties have been published for 2010 (i.e. three years into the campaign).3 The pooled data for physicians and nurses showed 59% compliance in internal medicine (2008: 56%), 77% in paediatrics (64%) and 84% in haemato-oncology (62%). For Germany as a whole, overall compliance was estimated to be 50% before the German campaign started in 2008.6 For hospitals performing observation studies, compliance was reported to be 60.9% at baseline and to have increased by 9e18% in 2013, depending on the type of unit.5,7 For instance, compliance rose from 62% to 69% in internal medicine, from 60% to 64% in surgery, from 69% to 87% in neonatology, and from 65% to 74% in interdisciplinary ICUs.7 However, as these data are based on a minority of facilities (e.g. on 73 ICUs for 2013), the number of hospitals in which the inverted U-shaped pattern described for the MHH occurred is unclear. The fact that physicians in all studies showed lower compliance than nurses indicated that they require particular scrutiny. Simultaneously, it has been asserted that, given differences between observed and selfperceived compliance, staff may define compliance differently from guidelines.8e10 As such, it is important to understand determinants of self-perceived compliance in order to better tailor interventions to their addressees. While the foundations on behavioural aspects related to hand hygiene are generally understood, and models for change in health care exist,11 it has been argued that psychological behaviour change theories and their application are still lacking and this is one reason why conclusive evidence regarding hand hygiene promotion is scarce.12 No intervention studies with explicit reference to psychological theories had been published until April 2011,13 and recent trials have been limited to nurses14,15 or are still underway.16,17 Exploratory studies have tended to consider hand hygiene behaviour (HHB) as reasoned actions directly influenced by behavioural intentions.8,18e20 However, only one study found this effect, and it was limited by a small sample size (N ¼ 104), low response rate (34%) and no differentiation between professional groups.20 Other studies used debatable measures, such as motivation not being operationalized as behavioural intention.18 Also, limitations of theories focusing on attitudes have
been pinpointed, arguing that HHB is an acquired habit rather than a reasoned action.13,16,21,22 There are two sides to this ‘habitual quality’ coin. First, habits tend to presume stable and supportive environments. Second, stage theories of behaviour change such as the Transtheoretical Model23 and the Health Action Process Approach (HAPA)24 allow the differentiation of healthcare workers psychologically in terms of HHB experience.13 The HAPA is particularly promising in this context. Generally, the HAPA is a model of preventive behaviours that integrates key concepts from most other behaviour models, and thus is highly generic and flexible in its application to different domains. It describes any given health-related behaviour and its changes along several states (‘stages’) from motivation [i.e. intending to behave in a certain manner (e.g. comply with guidelines)] through planning and the action itself (including habituation). Thus, it is comparable to the Transtheoretical Model, which also assumes different stages of change.23 However, besides behavioural planning (i.e. personal strategies about when, where and how to act and cope with relapses), the HAPA stresses two specific factors proximal to behaviour that have not been widely studied, let alone scrutinized in regard to HHB: e maintenance self-efficacy (i.e. belief in one’s capabilities to organize and execute courses of action that are required to sustain behaviour change and cope with relapses); and e action control [i.e. self-regulatory strategies where the ongoing behaviour is evaluated continuously (and, at best, automatically) against behavioural standards (e.g. guidelines)].24 Deficits in these parameters may make compliance a question of transforming behaviour into habitual behaviour rather than one of poor motivation. As such, the aim of this study was to test associations between these psychological factors and HHB among physicians and nurses. In order to take both sides of the ‘habitual coin’ into account, perceived social and physical attributes of the ward environment were considered, thus including parameters of cognitive behavioural science and human factor engineering.25 As nosocomial infections are a problem in German ICUs (15.3% in 1994, 18.6% in 2011),26 including MHH (28.2% in 2010),27 this study focused on ICUs.
Methods Setting The data were taken from a survey of physicians and nurses in MHH’s 10 ICUs and two haematopoietic stem cell transplantation units within the PSYGIENE project (PSYchologically optimised hand hyGIENE promotion). MHH is a university
T. von Lengerke et al. / Journal of Hospital Infection 91 (2015) 59e67 medical centre in the tertiary care sector with 1498 beds. Of the ICUs, five are surgical, two are internal, two are paediatric, and one is interdisciplinary.
Study participants All 433 physicians and 549 nurses working in the wards prior to the survey were identified using personnel controlling systems and directories, and were invited to participate in the study. The rationale for this was that within the PSYGIENE project, the survey was embedded in a cluster-randomized trial as one baseline assessment, and in this context was designed to be comprehensive (i.e. to include all ICUs and haematopoietic stem cell transplantation units at MHH, as well as all physicians and nurses on these wards). The Employees’ Council approved the study on 10th October 2012. The survey was conducted from 26th November 2012 to 25th January 2013. Questionnaires were distributed during morning meetings, handovers or via mailboxes, and were collected on-site, ensuring anonymity. Medical directors were briefed and their active support was ensured in order to maximize the response rate. The survey was announced to the central nursing management, head nurses and infection control personnel. Two Apple iPads were advertised as incentives for participation and recipients were drawn in a lottery.
Measures Table I shows the key measures. Following the HAPA,24,28 respondents who indicated ‘yes’ on the stage of change item were categorized as ‘actors’, those who indicated ‘no but intend to’ were categorized as ‘intenders’, and those who indicated any other category were categorized as ‘preintenders’. Responses to the hygienic hand disinfection item were dichotomized into ‘always’ and ‘not always’, as only six respondents (0.9%) indicated ‘often’ or less, and ‘always’ is most akin to compliance. Given the Cronbach’s alpha of action control, analyses involving this scale were repeated with each single item to identify which accounted for the given effects. Environmental factors were self-reported with items adapted from the TAA-KH-S, an instrument used to analyse work tasks in German hospitals.29 Sociodemographics Respondents indicated their sex and age [six categories: 60 years for anonymization purposes]. Highest level of education was assessed by an item following German demographic standards.30 Professional group, years of professional experience, length of service on ward and function were assessed.
Statistical analysis Physicians and nurses were compared in terms of selfreported compliance and psychosocial variables by crosstabulation or Student’s t-test. Subsequently, for both groups, self-reported compliance was analysed by psychosocial variables via cross-tabulation and multiple logistic regression using Statistical Package for the Social Sciences Version 21 (IBM Corp., Armonk, NY, USA).
61
Results Sample description and stage of change distribution In total, 307 physicians and 348 nurses returned an eligible questionnaire [response rates: 70.9% (physicians), 63.4% (nurses) and 66.7% (overall)]. Table II gives an overview of sample characteristics and findings for the stage of change variable. As defined by the stage of change algorithm,28 there were no pre-intenders (i.e. all respondents had the intention, at least, to disinfect their hands before and after tasks). Only five respondents indicated intention without implementation; this sample size was not suitable for separate analysis. Thus, the 99% of participants who were in the action phase as defined by the HAPA were included in the subsequent analysis (N ¼ 648).
Distribution of hygienic hand disinfection and psychosocial variables Of the physicians and nurses, 72.4% and 69.4%, respectively, stated that they always disinfect their hands when performing potentially infectious tasks (Table III). Significant differences emerged for psychosocial variables. Nurses had higher scores than physicians for planning, self-efficacy and action control (P < 0.05). The latter difference was largely due to higher awareness of standards (5.79 vs 4.94, P < 0.001); dı¨fferences in self-monitoring (5.95 vs 5.82, P ¼ 0.187) and self-regulatory capacity (5.09 vs 4.96, P ¼ 0.374) were insignificant between nurses and physicians (not shown). For perceived environmental factors, significantly more favourable personnel resources and cooperation on the ward were found among physicians.
Associations between hygienic hand disinfection and psychosocial variables Figure 1 presents the proportions of respondents who stated that they always disinfect their hands by psychosocial variables (tertile splits; Chi-square P-values below the abscissae). Of the environmental factors, only cooperation on the ward was associated with self-reported compliance, and only among physicians. Among respondents perceiving poor cooperation on the ward, 59.7% stated that they always disinfect their hands, compared with 86.2% among those who perceived good cooperation on the ward. For psychological variables, significant associations with compliance emerged consistently. Compliance was highest in groups with high values, ranging from 76.9% among nurses with high planning to 92.4% among physicians with high action control. Gradients were observed for all associations among physicians, while nurses with medium planning and medium self-efficacy had marginally lower compliance compared with nurses with low planning and low self-efficacy. Regarding individual action control items, linear relationships with compliance were found for self-monitoring and self-regulatory capacity, similar to the three-item scale (P < 0.001; not shown). For awareness of guidelines, compliance was marginally lower among respondents with medium awareness compared with those with low awareness, and respondents with strongest awareness had the highest compliance (physicians: P ¼ 0.002; nurses: P ¼ 0.030; not shown).
62
T. von Lengerke et al. / Journal of Hospital Infection 91 (2015) 59e67
Table I Items assessing state of change, hygienic hand disinfection behaviour and psychosocial factorsa Factor
Stage of change26,b
Hygienic hand disinfection behaviour Behavioural planning22,b (Cronbach’s alpha ¼ 0.70)
Maintenance self-efficacy22*,b (Cronbach’s alpha ¼ 0.76)
Action control22,b (Cronbach’s alpha ¼ 0.44)
Personnel resources27 (Cronbach’s alpha ¼ 0.65)
Material resources27 (Cronbach’s alpha ¼ 0.72)
Organizational problems27 (Cronbach’s alpha ¼ 0.62)
Cooperation on the ward27 (Cronbach’s alpha ¼ 0.71)
a b
Item(s)
Measure
e Of late, have you disinfected your hands before and after tasks associated with a risk of infection?
e When performing potentially infectious tasks, I disinfect my hands. Of late, I have precisely planned. e to disinfect my hands before and after every potentially infectious task even if I have to change gloves in between e how to deal with barriers and events impeding hand disinfection e how I react after noticing that I forgot to disinfect my hands. I am confident that I am able to disinfect my hands before and after every potentially infectious task even if. e I had recently forgotten to do so e I have to get the disinfectant first e the situation at hand is an interrupted patient contact only e I know how to disinfect my hands according to the guidelines (awareness of standards) e I make sure that I disinfect my hands before and after every potentially infectious task (self-monitoring) e I have to make an effort to disinfect my hands before and after every potentially infectious task (self-regulatory effort, recoded to indicate self-regulatory ease) e Personnel resources in terms of physicians are appropriate on my ward e Personnel resources in terms of nurses are appropriate on my ward e Space resources on my ward (e.g. for patient isolation) are appropriate e The situation regarding medical devices is appropriate e On my ward, one frequently has to deal with problems due to occupancy e On my ward, one frequently has to deal with problems due to absenteeism On my ward, cooperation with. e colleagues e superiors e patients’ relatives works well
Yes, and it has become routine for me/Yes, but it has not yet become routine for me/No, but I do intend to do so/No, but I have been contemplating it/No, and I have not been contemplating it Always/mostly/often/only occasionally/rather rarely Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert-scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
German originals available upon request from the corresponding author. Generic operationalizations applied on hand disinfection.
As compliance was not associated with sex, age, education, executive function, professional experience or length of service (all P > 0.05), these factors were omitted from the multiple logistic regression analyses to prevent over-adjustment. Thus, adjustments were made for ward alone as a proxy for
unconsidered environmental characteristics (not shown). Among physicians, the odds of compliance only increased significantly with cooperation on the ward (by 50%; Table IV). Self-efficacy and action control were significantly associated with increased odds of compliance. Among nurses, the only
T. von Lengerke et al. / Journal of Hospital Infection 91 (2015) 59e67
63
Table II Description of sample by sociodemographics, job attributes and stage of change regarding hygienic hand disinfectiona
Sex Age (years)
Level of education
Executive functionb
Women Men 60 Lower secondary school Intermediate secondary school Upper secondary school University or university of applied sciences Other degree No degree Yes No
Professional Experience (years) Length of service on unit (years) Stage of changec
Pre-intenders Intenders Actors
Total N ¼ 655
Physicians N ¼ 307
Nurses N ¼ 348
(%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%)
381 (59.3) 262 (40.7) 0 (0.0) 196 (30.1) 237 (36.3) 156 (23.9) 58 (8.9) 5 (0.8) 4 (0.6) 135 (20.8) 185 (28.4) 324 (49.8)
100 (33.1) 202 (66.9) 0 (0.0) 61 (19.9) 149 (48.7) 69 (22.5) 25 (8.2) 2 (0.7) 0 (0.0) 0 (0.0) 0 (0.0) 305 (100)
281 (82.4) 60 (17.6) 0 (0.0) 135 (39.0) 88 (25.4) 87 (25.1) 33 (9.5) 3 (0.9) 4 (1.2) 135 (39.1) 185 (53.6) 19 (5.5)
N (%) N (%) N (%) N (%) Mean SD Mean SD N (%) N (%) N (%)
2 (0.3) 0 (0.0) 111 (17.3) 529 (82.7) 12.2 9.4 6.5 7.1 0 (0.0) 5 (0.8) 648 (99.2)
0 (0.0) 0 (0.0) 97 (32.3) 203 (67.7) 10.1 8.0 4.1 4.8 0 (0.0) 2 (0.7) 304 (99.3)
2 (0.6) 0 (0.0) 14 (4.1) 326 (95.9) 14.2 10.2 8.5 7.8 0 (0.0) 3 (0.9) 344 (99.1)
N N N N N N N N N N N N
SD, standard deviation. a Any totals not adding up to N ¼ 655 due to missing values. b Among nurses, only head nurses of units or their deputies were counted as executive; among physicians, senior physicians were counted as executive. c See text for algorithm.
Table III Self-reported hygienic hand disinfection and psychosocial factors among physicians and nursesa
Hygienic hand disinfection Behavioural planning
Always Not always (1e7)
Maintenance self-efficacy
(1e7)
Action control
(1e7)
Personnel resources
(1e7)
Material resources
(1e7)
Organizational problems
(1e7)
Cooperation on the ward
(1e7)
N (%) N (%) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Physicians (N ¼ 304)
Nurses (N ¼ 344)
220 (72.4) 84 (27.6) 4.41 1.51 5.57 1.28 5.25 1.12 3.91 1.64 4.17 1.64 5.10 1.57 5.72 0.98
238 (69.4) 105 (30.6) 4.79 1.33 5.84 1.24 5.62 1.05 3.60 1.55 4.31 1.72 5.07 1.61 5.33 0.97
P
0.405 0.001 0.007
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Psychosocial determinants of self-reported hand hygiene behaviour: a survey comparing physicians and nurses in intensive care units T. von Lengerke a, *, B. Lutze a, K. Graf b, C. Krauth c, K. Lange a, L. Schwadtke b, J. Stahmeyer c, I.F. Chaberny b a
Medical Psychology Unit, Hannover Medical School, Hannover, Lower Saxony, Germany Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Lower Saxony, Germany c Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover Medical School, Hannover, Lower Saxony, Germany b
A R T I C L E
I N F O
Article history: Received 30 July 2014 Accepted 9 April 2015 Available online 9 June 2015 Keywords: Hand hygiene compliance Intensive care personnel Nosocomial infection prevention Self-regulation Social work environment
S U M M A R Y
Background: Research applying psychological behaviour change theories to hand hygiene compliance is scarce, especially for physicians. Aim: To identify psychosocial determinants of self-reported hand hygiene behaviour (HHB) of physicians and nurses in intensive care units (ICUs). Methods: A cross-sectional survey using a self-administered questionnaire that applied concepts from the Health Action Process Approach on hygienic hand disinfection was conducted in 10 ICUs and two haematopoietic stem cell transplantation units at Hannover Medical School, Germany. Self-reported compliance was operationalized as always disinfecting one’s hands when given tasks associated with risk of infection. Using seven-point Likert scales, behavioural planning, maintenance self-efficacy and action control were assessed as psychological factors, and personnel and material resources, organizational problems and cooperation on the ward were assessed as perceived environmental factors. Multiple logistic regression analysis was employed. Findings: In total, 307 physicians and 348 nurses participated in this study (response rates 70.9% and 63.4%, respectively). Self-reported compliance did not differ between the groups (72.4% vs 69.4%, P ¼ 0.405). While nurses reported stronger planning, self-efficacy and action control, physicians indicated better personnel resources and cooperation on the ward (P < 0.02). Self-efficacy [odds ratio (OR) 1.4, P ¼ 0.041], action control (OR 1.8, P < 0.001) and cooperation on the ward (OR 1.5, P ¼ 0.036) were positively associated with HHB among physicians, but only action control was positively associated with HHB among nurses (OR 1.6, P < 0.001). Conclusion: The associations between action control (self-regulatory strategies where behaviour is evaluated continuously and automatically against guidelines) and compliance
* Corresponding author. Address: Medical Psychology Unit, Hannover Medical School, Carl-Neuberg-Str. 1 (OE 5430), 30625 Hannover, Germany. Tel.: þ 49 (0)511 532 4445; fax: þ 49 (0)511 532 4214. E-mail address: [email protected] (T. von Lengerke). http://dx.doi.org/10.1016/j.jhin.2015.04.018 0195-6701/ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
60
T. von Lengerke et al. / Journal of Hospital Infection 91 (2015) 59e67 indicate that HHB is a habit in need of self-monitoring. The fact that perceived cooperation on the ward was the only environmental correlate of HHB among physicians stresses the importance of team-directed interventions. ª 2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction Hand hygiene compliance is generally lower in physicians than in nurses, and physicians do not respond as well to multimodal interventions.1e3 A report from Australia found that compliance followed an inverted U-shaped pattern around the 2006e2007 ‘Clean Hands Save Lives’ campaign, especially in physicians.2 Comparable trends were observed in intensive care units (ICUs) at Hannover Medical School (MHH), Germany.4 During the German ‘Clean Care is Safer Care’ campaign,5 hygienic hand disinfection compliance of physicians was highest in 2011 at 64%, up from 53% in 2008 (pre-campaign) and dropping to 48% in 2013. Among nurses, this trend was 57% (2008), 71% (2009/10) and 56% (2013). Data for other medical specialties have been published for 2010 (i.e. three years into the campaign).3 The pooled data for physicians and nurses showed 59% compliance in internal medicine (2008: 56%), 77% in paediatrics (64%) and 84% in haemato-oncology (62%). For Germany as a whole, overall compliance was estimated to be 50% before the German campaign started in 2008.6 For hospitals performing observation studies, compliance was reported to be 60.9% at baseline and to have increased by 9e18% in 2013, depending on the type of unit.5,7 For instance, compliance rose from 62% to 69% in internal medicine, from 60% to 64% in surgery, from 69% to 87% in neonatology, and from 65% to 74% in interdisciplinary ICUs.7 However, as these data are based on a minority of facilities (e.g. on 73 ICUs for 2013), the number of hospitals in which the inverted U-shaped pattern described for the MHH occurred is unclear. The fact that physicians in all studies showed lower compliance than nurses indicated that they require particular scrutiny. Simultaneously, it has been asserted that, given differences between observed and selfperceived compliance, staff may define compliance differently from guidelines.8e10 As such, it is important to understand determinants of self-perceived compliance in order to better tailor interventions to their addressees. While the foundations on behavioural aspects related to hand hygiene are generally understood, and models for change in health care exist,11 it has been argued that psychological behaviour change theories and their application are still lacking and this is one reason why conclusive evidence regarding hand hygiene promotion is scarce.12 No intervention studies with explicit reference to psychological theories had been published until April 2011,13 and recent trials have been limited to nurses14,15 or are still underway.16,17 Exploratory studies have tended to consider hand hygiene behaviour (HHB) as reasoned actions directly influenced by behavioural intentions.8,18e20 However, only one study found this effect, and it was limited by a small sample size (N ¼ 104), low response rate (34%) and no differentiation between professional groups.20 Other studies used debatable measures, such as motivation not being operationalized as behavioural intention.18 Also, limitations of theories focusing on attitudes have
been pinpointed, arguing that HHB is an acquired habit rather than a reasoned action.13,16,21,22 There are two sides to this ‘habitual quality’ coin. First, habits tend to presume stable and supportive environments. Second, stage theories of behaviour change such as the Transtheoretical Model23 and the Health Action Process Approach (HAPA)24 allow the differentiation of healthcare workers psychologically in terms of HHB experience.13 The HAPA is particularly promising in this context. Generally, the HAPA is a model of preventive behaviours that integrates key concepts from most other behaviour models, and thus is highly generic and flexible in its application to different domains. It describes any given health-related behaviour and its changes along several states (‘stages’) from motivation [i.e. intending to behave in a certain manner (e.g. comply with guidelines)] through planning and the action itself (including habituation). Thus, it is comparable to the Transtheoretical Model, which also assumes different stages of change.23 However, besides behavioural planning (i.e. personal strategies about when, where and how to act and cope with relapses), the HAPA stresses two specific factors proximal to behaviour that have not been widely studied, let alone scrutinized in regard to HHB: e maintenance self-efficacy (i.e. belief in one’s capabilities to organize and execute courses of action that are required to sustain behaviour change and cope with relapses); and e action control [i.e. self-regulatory strategies where the ongoing behaviour is evaluated continuously (and, at best, automatically) against behavioural standards (e.g. guidelines)].24 Deficits in these parameters may make compliance a question of transforming behaviour into habitual behaviour rather than one of poor motivation. As such, the aim of this study was to test associations between these psychological factors and HHB among physicians and nurses. In order to take both sides of the ‘habitual coin’ into account, perceived social and physical attributes of the ward environment were considered, thus including parameters of cognitive behavioural science and human factor engineering.25 As nosocomial infections are a problem in German ICUs (15.3% in 1994, 18.6% in 2011),26 including MHH (28.2% in 2010),27 this study focused on ICUs.
Methods Setting The data were taken from a survey of physicians and nurses in MHH’s 10 ICUs and two haematopoietic stem cell transplantation units within the PSYGIENE project (PSYchologically optimised hand hyGIENE promotion). MHH is a university
T. von Lengerke et al. / Journal of Hospital Infection 91 (2015) 59e67 medical centre in the tertiary care sector with 1498 beds. Of the ICUs, five are surgical, two are internal, two are paediatric, and one is interdisciplinary.
Study participants All 433 physicians and 549 nurses working in the wards prior to the survey were identified using personnel controlling systems and directories, and were invited to participate in the study. The rationale for this was that within the PSYGIENE project, the survey was embedded in a cluster-randomized trial as one baseline assessment, and in this context was designed to be comprehensive (i.e. to include all ICUs and haematopoietic stem cell transplantation units at MHH, as well as all physicians and nurses on these wards). The Employees’ Council approved the study on 10th October 2012. The survey was conducted from 26th November 2012 to 25th January 2013. Questionnaires were distributed during morning meetings, handovers or via mailboxes, and were collected on-site, ensuring anonymity. Medical directors were briefed and their active support was ensured in order to maximize the response rate. The survey was announced to the central nursing management, head nurses and infection control personnel. Two Apple iPads were advertised as incentives for participation and recipients were drawn in a lottery.
Measures Table I shows the key measures. Following the HAPA,24,28 respondents who indicated ‘yes’ on the stage of change item were categorized as ‘actors’, those who indicated ‘no but intend to’ were categorized as ‘intenders’, and those who indicated any other category were categorized as ‘preintenders’. Responses to the hygienic hand disinfection item were dichotomized into ‘always’ and ‘not always’, as only six respondents (0.9%) indicated ‘often’ or less, and ‘always’ is most akin to compliance. Given the Cronbach’s alpha of action control, analyses involving this scale were repeated with each single item to identify which accounted for the given effects. Environmental factors were self-reported with items adapted from the TAA-KH-S, an instrument used to analyse work tasks in German hospitals.29 Sociodemographics Respondents indicated their sex and age [six categories: 60 years for anonymization purposes]. Highest level of education was assessed by an item following German demographic standards.30 Professional group, years of professional experience, length of service on ward and function were assessed.
Statistical analysis Physicians and nurses were compared in terms of selfreported compliance and psychosocial variables by crosstabulation or Student’s t-test. Subsequently, for both groups, self-reported compliance was analysed by psychosocial variables via cross-tabulation and multiple logistic regression using Statistical Package for the Social Sciences Version 21 (IBM Corp., Armonk, NY, USA).
61
Results Sample description and stage of change distribution In total, 307 physicians and 348 nurses returned an eligible questionnaire [response rates: 70.9% (physicians), 63.4% (nurses) and 66.7% (overall)]. Table II gives an overview of sample characteristics and findings for the stage of change variable. As defined by the stage of change algorithm,28 there were no pre-intenders (i.e. all respondents had the intention, at least, to disinfect their hands before and after tasks). Only five respondents indicated intention without implementation; this sample size was not suitable for separate analysis. Thus, the 99% of participants who were in the action phase as defined by the HAPA were included in the subsequent analysis (N ¼ 648).
Distribution of hygienic hand disinfection and psychosocial variables Of the physicians and nurses, 72.4% and 69.4%, respectively, stated that they always disinfect their hands when performing potentially infectious tasks (Table III). Significant differences emerged for psychosocial variables. Nurses had higher scores than physicians for planning, self-efficacy and action control (P < 0.05). The latter difference was largely due to higher awareness of standards (5.79 vs 4.94, P < 0.001); dı¨fferences in self-monitoring (5.95 vs 5.82, P ¼ 0.187) and self-regulatory capacity (5.09 vs 4.96, P ¼ 0.374) were insignificant between nurses and physicians (not shown). For perceived environmental factors, significantly more favourable personnel resources and cooperation on the ward were found among physicians.
Associations between hygienic hand disinfection and psychosocial variables Figure 1 presents the proportions of respondents who stated that they always disinfect their hands by psychosocial variables (tertile splits; Chi-square P-values below the abscissae). Of the environmental factors, only cooperation on the ward was associated with self-reported compliance, and only among physicians. Among respondents perceiving poor cooperation on the ward, 59.7% stated that they always disinfect their hands, compared with 86.2% among those who perceived good cooperation on the ward. For psychological variables, significant associations with compliance emerged consistently. Compliance was highest in groups with high values, ranging from 76.9% among nurses with high planning to 92.4% among physicians with high action control. Gradients were observed for all associations among physicians, while nurses with medium planning and medium self-efficacy had marginally lower compliance compared with nurses with low planning and low self-efficacy. Regarding individual action control items, linear relationships with compliance were found for self-monitoring and self-regulatory capacity, similar to the three-item scale (P < 0.001; not shown). For awareness of guidelines, compliance was marginally lower among respondents with medium awareness compared with those with low awareness, and respondents with strongest awareness had the highest compliance (physicians: P ¼ 0.002; nurses: P ¼ 0.030; not shown).
62
T. von Lengerke et al. / Journal of Hospital Infection 91 (2015) 59e67
Table I Items assessing state of change, hygienic hand disinfection behaviour and psychosocial factorsa Factor
Stage of change26,b
Hygienic hand disinfection behaviour Behavioural planning22,b (Cronbach’s alpha ¼ 0.70)
Maintenance self-efficacy22*,b (Cronbach’s alpha ¼ 0.76)
Action control22,b (Cronbach’s alpha ¼ 0.44)
Personnel resources27 (Cronbach’s alpha ¼ 0.65)
Material resources27 (Cronbach’s alpha ¼ 0.72)
Organizational problems27 (Cronbach’s alpha ¼ 0.62)
Cooperation on the ward27 (Cronbach’s alpha ¼ 0.71)
a b
Item(s)
Measure
e Of late, have you disinfected your hands before and after tasks associated with a risk of infection?
e When performing potentially infectious tasks, I disinfect my hands. Of late, I have precisely planned. e to disinfect my hands before and after every potentially infectious task even if I have to change gloves in between e how to deal with barriers and events impeding hand disinfection e how I react after noticing that I forgot to disinfect my hands. I am confident that I am able to disinfect my hands before and after every potentially infectious task even if. e I had recently forgotten to do so e I have to get the disinfectant first e the situation at hand is an interrupted patient contact only e I know how to disinfect my hands according to the guidelines (awareness of standards) e I make sure that I disinfect my hands before and after every potentially infectious task (self-monitoring) e I have to make an effort to disinfect my hands before and after every potentially infectious task (self-regulatory effort, recoded to indicate self-regulatory ease) e Personnel resources in terms of physicians are appropriate on my ward e Personnel resources in terms of nurses are appropriate on my ward e Space resources on my ward (e.g. for patient isolation) are appropriate e The situation regarding medical devices is appropriate e On my ward, one frequently has to deal with problems due to occupancy e On my ward, one frequently has to deal with problems due to absenteeism On my ward, cooperation with. e colleagues e superiors e patients’ relatives works well
Yes, and it has become routine for me/Yes, but it has not yet become routine for me/No, but I do intend to do so/No, but I have been contemplating it/No, and I have not been contemplating it Always/mostly/often/only occasionally/rather rarely Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert-scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
Seven-point Likert scales from ‘not correct at all’ (1) to ‘fully correct’ (7)
German originals available upon request from the corresponding author. Generic operationalizations applied on hand disinfection.
As compliance was not associated with sex, age, education, executive function, professional experience or length of service (all P > 0.05), these factors were omitted from the multiple logistic regression analyses to prevent over-adjustment. Thus, adjustments were made for ward alone as a proxy for
unconsidered environmental characteristics (not shown). Among physicians, the odds of compliance only increased significantly with cooperation on the ward (by 50%; Table IV). Self-efficacy and action control were significantly associated with increased odds of compliance. Among nurses, the only
T. von Lengerke et al. / Journal of Hospital Infection 91 (2015) 59e67
63
Table II Description of sample by sociodemographics, job attributes and stage of change regarding hygienic hand disinfectiona
Sex Age (years)
Level of education
Executive functionb
Women Men 60 Lower secondary school Intermediate secondary school Upper secondary school University or university of applied sciences Other degree No degree Yes No
Professional Experience (years) Length of service on unit (years) Stage of changec
Pre-intenders Intenders Actors
Total N ¼ 655
Physicians N ¼ 307
Nurses N ¼ 348
(%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) (%)
381 (59.3) 262 (40.7) 0 (0.0) 196 (30.1) 237 (36.3) 156 (23.9) 58 (8.9) 5 (0.8) 4 (0.6) 135 (20.8) 185 (28.4) 324 (49.8)
100 (33.1) 202 (66.9) 0 (0.0) 61 (19.9) 149 (48.7) 69 (22.5) 25 (8.2) 2 (0.7) 0 (0.0) 0 (0.0) 0 (0.0) 305 (100)
281 (82.4) 60 (17.6) 0 (0.0) 135 (39.0) 88 (25.4) 87 (25.1) 33 (9.5) 3 (0.9) 4 (1.2) 135 (39.1) 185 (53.6) 19 (5.5)
N (%) N (%) N (%) N (%) Mean SD Mean SD N (%) N (%) N (%)
2 (0.3) 0 (0.0) 111 (17.3) 529 (82.7) 12.2 9.4 6.5 7.1 0 (0.0) 5 (0.8) 648 (99.2)
0 (0.0) 0 (0.0) 97 (32.3) 203 (67.7) 10.1 8.0 4.1 4.8 0 (0.0) 2 (0.7) 304 (99.3)
2 (0.6) 0 (0.0) 14 (4.1) 326 (95.9) 14.2 10.2 8.5 7.8 0 (0.0) 3 (0.9) 344 (99.1)
N N N N N N N N N N N N
SD, standard deviation. a Any totals not adding up to N ¼ 655 due to missing values. b Among nurses, only head nurses of units or their deputies were counted as executive; among physicians, senior physicians were counted as executive. c See text for algorithm.
Table III Self-reported hygienic hand disinfection and psychosocial factors among physicians and nursesa
Hygienic hand disinfection Behavioural planning
Always Not always (1e7)
Maintenance self-efficacy
(1e7)
Action control
(1e7)
Personnel resources
(1e7)
Material resources
(1e7)
Organizational problems
(1e7)
Cooperation on the ward
(1e7)
N (%) N (%) Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Physicians (N ¼ 304)
Nurses (N ¼ 344)
220 (72.4) 84 (27.6) 4.41 1.51 5.57 1.28 5.25 1.12 3.91 1.64 4.17 1.64 5.10 1.57 5.72 0.98
238 (69.4) 105 (30.6) 4.79 1.33 5.84 1.24 5.62 1.05 3.60 1.55 4.31 1.72 5.07 1.61 5.33 0.97
P
0.405 0.001 0.007
