Determinants of non-compliance with hand hygiene using a covert direct observation methodology

The Hawthorne effect may result in an overestimation of hand hygiene (HH) compliance during routine observations, which may weaken the significance of factors associated with non-compliance. The aim of this study was to examine professional and healthcare determinants of HH non-compliance using covert observation.

A cross-sectional study design was conducted among healthcare workers (HCWs) at a tertiary care hospital in Saudi Arabia. HH observations were conducted discreetly by trained observers, followed by a questionnaire and an audit to identify possible determinants of HH non-compliance. HH non-compliance was assessed according to the World Health Organisation's (WHO) five-moments for HH, while inappropriate compliance was evaluated by additionally considering incorrect HH technique.

A total of 6580 HH opportunities were observed by 502 HCWs. The overall non-compliance rate was 54.1% with inappropriate compliance at 71.1%. Significant factors associated (P<0.05) with non-compliance included lack of HH education/training, lack of job promotion, working in the emergency department, lack of HH auditing, absence of pocket-sized alcohol-based handrub (ABHR) bottles, inconveniently placed hand washing sinks and ABHR wall dispensers, infrequent replacement of empty ABHR wall dispensers, and lack of nearby promoting posters. With few exceptions, the determinants of HH inappropriate compliance were similar to those of HH non-compliance, when objectively audited by the researcher.

The findings underscore the importance of HH training and supportive healthcare infrastructures. These insights may assist decision-makers in identifying specific work environment factors that could improve HH compliance through appropriate interventions. Further research is required to evaluate the impact of these suggested modifications on HH compliance.