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.

Objective: To study potential determinants of hand hygiene compliance among healthcare workers in the hospital setting.
Design: 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.
Setting: Intensive care units and surgical departments of 5 hospitals of varying size in The Netherlands.
Participants: A total of 65 nurses, attending physicians, medical residents, and medical students.
Results: 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.
Conclusion: 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.