Future systems of measurement for hand hygiene in healthcare

Abstract

Hand hygiene is considered a key infection prevention strategy against the challenge of healthcare associated infections, as it prevents cross-transmission of microorganisms which may cause harm. Despite this, compliance amongst healthcare professionals is often poor. Considerable attention has been placed on developing interventions to increase hand hygiene, however known problems with measurement make determining improvement from established baselines difficult. This thesis addresses measurement through three research themes: The importance of meaningful data (Study 1), the potential for technology (Study 2), and the influence of human behaviour (Study 3). These are considered in relation to guidelines developed by the World Health Organisation (WHO) (My 5 Moments for Hand Hygiene). The thesis output provides recommendations for the healthcare setting, technology industry and research community by forming a new conceptual and integrated way of considering the measurement of hand hygiene compliance. A mixed methods approach was applied using a single case study methodology comprising three studies (two qualitative, one quantitative), based at a UK acute National Health Service Trust. Healthcare professionals involved in the current hand hygiene measurement process participated in all three studies (N=47). Methods included structured literature reviews, participant observation, one-to-one and group interviews, nonparticipant observation and analysis of existing case study site data. In Study 1 healthcare professionals identified a lack of clarity regarding feedback, and a lack of synergy between hand hygiene training and measurement. Combined with data accuracy flaws, their view was that the current hand hygiene measurement process produced meaningless data. Study 2 investigated healthcare professional views regarding the potential of technology to measure hand hygiene. It found that whilst current innovations are unable to detect all the WHO 5 Moments, healthcare professionals are interested in their potential to aid measurement and compliance. However they raised concerns about Fit for Purpose, anonymity and resistance, and over-reliance on technology and habituation. Interestingly participants suggested that hand hygiene across all WHO 5 Moments is not equal, expecting higher levels of adherence to Moments 2 and 3 than Moments 1, 4 and 5. Study 3 explored this, investigating the theory of Inherent and Elective hand hygiene behaviour. Inherent can be linked to Moments 2 and 3, through activities likely to stimulate an automatic “disgust” reaction within humans. Hand hygiene was significantly lower when healthcare professionals performed Elective rather than Inherent activities. The research developed Inherent and Elective theory further by proposing it as a lens with which to view the WHO 5 Moments and develop strategies for improved compliance. Understanding that hand hygiene is less likely at Elective activities, linked to Moments 1, 4 and 5 suggests these as key areas of focus for technology development. Acknowledging that hand hygiene may be more instinctive at Moment 2 and 3 may be useful when planning education, leading to reduced healthcare professional apathy towards hand hygiene. Involvement of healthcare professionals in exploring measurement processes and developing technologies for hand hygiene is proposed as key to ensure data produced by future methods of measurement is meaningful, vital to ensure desired behaviour change