Developing and Evaluating A Novel Intervention to Improve the Hand Hygiene Behaviour of Nurses In Acute Care Hospital Units in the United States

Healthcare associated infections burden patients, raise healthcare costs, and can lead to death. It has been shown that adequate hand hygiene among healthcare workers is the simplest and most effective measure for preventing these infections. However, hand hygiene compliance rates are generally poor, with many initiatives seeking to address this problem. While there has been success in producing short-term changes, the effects are typically minimal and not sustained. The aim of this thesis was to develop and evaluate an original hand hygiene intervention based on the Behaviour Centred Design approach for nurses in acute care hospital units. The thesis assessed the current state of hand hygiene interventions through a systematic literature review and conducted formative research to explore underutilized factors that influence this behaviour. The review found that current interventions focus on individual-level psychological factors and incorporate behaviour change techniques that are cognitive in nature; for example, many of the studies had nurses create goals and plan how to best facilitate hand hygiene, compared both individuals’ and the group’s behaviours to others, and focused on the consequences arising from not practicing hand hygiene. The formative research— which used a questionnaire administered to a panel of nurses working in acute care units of US hospitals— discovered that nurses’ compliance is influenced by factors including management’s openness in communication, increased interactions with patients and peers, and reduction in busyness and cognitive load. These findings influenced the creation of a three-part original intervention, the Mainspring Intervention, consisting of: a self-affirmation exercise to reduce defensiveness, a message that challenged nurses’ perceptions about their practice, and an implementation intention activity to link behaviour to a cue. The intervention was evaluated in a multiple baseline study across two hospitals in the US during 2016-2017. Analysis of the outcome variable— the observed hand hygiene compliance— showed a statistically significant increase in compliance rates at the aggregate level, with striking variation in impact at the hospital unit-level. The evaluation process found that relatively few nurses were reached by the intervention and those who were reached did not actively engage. In addition, the context in which the intervention was delivered impacted the nurses’ responses to the intervention itself.