Predictors of hand hygiene attitudes among Saudi healthcare workers of the intensive care unit in Saudi Arabia

Abstract

Healthcare-associated infections present a challenge to healthcare systems, particularly critical care units. Hand hygiene emerges as a crucial element in infection control, acting as a vital link between healthcare workers, patients, and pathogens. Positive attitudes, motivated by a genuine concern for patient safety, are recognized as major predictors of hand hygiene compliance among healthcare workers. This study aims to assess the attitudes of ICU staff toward hand hygiene and identify factors that influence these attitudes. A cross-sectional survey of intensive care unit staff in seven large Saudi hospitals was conducted using an anonymous, self-reporting questionnaire to examine the attitudes of ICU personnel about hand hygiene and determine the factors that impact these attitudes. A regression analysis was used to determine the determinants of hand hygiene attitudes. Of the 600 respondents, 93% rated their hand hygiene knowledge as good, and 71% received hand hygiene training from their hospital. Most respondents (78%) had previously experienced healthcare-associated infections. The majority reported a favorable overall attitude toward hand hygiene (M = 4.15, SD = 0.85). Attitudes toward hand hygiene were significantly associated with perceived knowledge (β = 0.32, p < 0.001), prior hand hygiene training (β = 0.13, p < 0.05), and years of experience (β = − 0.10, p < 0.05). Healthcare workers in the ICU have a generally positive attitude toward hand hygiene. Such attitudes were correlated with hand hygiene knowledge, prior training, and job experience. The study’s findings can help to inform health promotion initiatives and campaigns aimed at achieving long-term improvements in hand hygiene behaviors.

Introduction

Healthcare-related infections (HAIs) pose a challenge within healthcare systems that face the weight of longer hospital stays and increasing financial expenditures, while Healthcare Workers (HCWs) battle with the emotional toll of witnessing the agony of patients¹. The urgency of addressing this issue cannot be emphasized, with lives at stake and healthcare resources stretched thin². Even though the intensive care unit (ICU) typically occupies only a small proportion of all hospital beds, it is responsible for a disproportionate amount of hospital activities³. Patients in ICUs are especially vulnerable due to the additional complexity of their illness, the amount of disruptive monitoring and assistance equipment they utilize, and the frequency of procedures and blood draws⁴. These predictors increase the likelihood of safety errors and subsequent harm. HAIs can cause additional preventable patient harm in any setting⁴. Nearly 20% of all hospitalized patients' HAI diagnoses are obtained in ICUs. These infections have high rates of morbidity and death as well as substantial expenditures for the healthcare system, patients, and their families⁵.

Hand hygiene plays a vital role in infection control. It is the most effective and efficient way to minimize the further spread of the infection⁶. Handwashing or sanitization, when done rigorously and regularly, acts as a sentinel, interrupting this transmission chain. However, the achievement of compliance with hand hygiene procedures is a complicated process due to several predictors, encompassing human, organizational, and environmental variables⁷. Understanding the predictors of hand hygiene could enhance compliance and maintenance, which helps to reduce HAIs. Individual-level characteristics, such as HCW attitudes, appear as important predictors⁸. Positive attitudes, motivated by a real concern for patient safety, are the driving force behind rigorous hand hygiene measures. The literature highlights the varying degrees of attitudes toward hand hygiene among HCWs⁹.

Analyzed data from the Saudi Ministry of Health (MoH) about sentinel incidents from 2012 to 2015 revealed that 91% of these occurrences were categorized as avoidable. Saudi Arabia took measures to address this problem by implementing strategies to minimize risks and enhance the safety and quality of healthcare. However, few studies have focused on the patient's safety measures in the ICU¹⁰. The primary aim of this study is to assess the attitudes of ICU staff toward hand hygiene and identify factors that influence these attitudes. To the best of our knowledge, this is the first study that examines the attitudes toward hand hygiene among a randomized sample of ICU HCWs recruited from various Saudi hospitals. The study aims to contribute to current efforts to improve patient safety and quality of treatment in the ICU environment by understanding the attitudes and their influencing predictors to adopt the best practices in hand hygiene.

Methods

Study design and setting

The study was carried out in the intensive care units of seven large hospitals in the Saudi Arabian region of Riyadh. We employed a cross-sectional analytical design, conducted from November 1st to 15th, 2023.

Study participants and sampling

The study involved a random selection of HCWs who provide ICU care to patients in seven major hospitals located in the Riyadh region of Saudi Arabia. The hospitals had an average capacity of 800 beds with a 1:4 average nurse-to-patient ratio in the ICUs. A minimal sample size of 580 was determined by utilizing a 5% margin of error, a 95% confidence level, a 50% response rate, and an 80% prior estimate level of hand hygiene attitudes¹¹. The method of simple random sampling was used by creating a comprehensive list of all HCWs in the ICU and then selecting individuals using an automated random selection process. A total of 680 HCWs received the invitation to participate in the online survey, and 600 of these individuals responded (response rate = 88%).

Measures and data collection

A self-reporting, anonymous questionnaire that was adopted from a reliable and valid source was employed as the study instrument, which used a behavior change theoretical framework to identify items that specifically attitudes toward hand hygiene¹². The questionnaire has undergone pre-validation using both qualitative and quantitative methodologies. The first stage included doing a content analysis of qualitative open-ended questions. In the second step, exploratory factor analysis was used to analyze the quantitative data¹². In our study, the questionnaire was tested with a subset of our population and no modifications were required. Table 1 displays the questionnaire consisting of 20 questions that pertain to demographic data, prior hand hygiene instruction, and attitudes toward hand hygiene. The study measurement presented a good internal consistency with Cronbach’s alpha = 0.85, illustrated in Table 2. A Likert scale with five points, ranging from “strongly disagree” to “strongly agree,” is used for each attitude measuring item. A computed score of more than 75% was regarded as good, a score of 50–74% as moderate, and a score of less than 50% as poor^13–15. The questionnaire was distributed online to randomly selected HCWs who were given explicit instructions on how to complete the survey. Before the study’s implementation, a pilot study was undertaken to assess the practicality and applicability of the research design and data collection procedures. Ethical considerations” where you can add the paragraph presented in the measure’s subsection “Before data collection, informed consent was obtained from all subjects. Methods were performed in accordance with the Declaration of Helsinki and relevant guidelines and regulations The study was approved by the King Fahad Medical City Institutional Review Board under number1R800010471 and Federal Wide Assurance number FWA00018774.

Table 1.

Respondents demographic characteristics.

Characteristic	Description	N (%)
Healthcare profession category	Laboratory Specialist	20 (3.3)
	Nurse	300 (50)
	Pharmacist	12 (2.0)
	Physical therapist	34 (5.7)
	Physician	44 (7.3)
	Radiology Therapist	26 (4.3)
	Respiratory Therapist	56 (9.3)
	Other	108 (18)
Sex	Female	446 (74.3)
	Male	154 (25.7)
Years of experience in healthcare	Less than 1 year	50 (8.3)
	1–5 years	158 (26.3)
	6–10 years	158 (26.3)
	More than 10 years	234 (39)
Do you provide direct care to patients	No	192 (32)
	Yes	408 (68)
How would you rate your hand hygiene knowledge	Good	558 (93)
	Poor	42 (7)
Have you had any previous hand hygiene training from the infection control department	No	174 (29)
	Yes	426 (71)
Have you experienced any hospital-associated infections before	No	358 (59.7)
	Yes	242 (40.3)
How would you describe your workload in the hospital	It is manageable	176 (29.3)
	It is not manageable	424 (70.7)

Table 2.

Perceptions and Attitudes of ICU HCWs Towards Hand Hygiene.

Item no	Characteristic	Strongly disagree	Disagree	Neutral	Agree	Strongly agree	Mean ± SD	All items Mean ± SD	Cronbach’s alpha
2	Hand hygiene is a habit	2.0	4.7	0	22.6	70.6	4.55 ± 0.88	4.15	0.85
3	Hand hygiene is important to me	0	16.7	0	83	0	3.67 ± 0.75
4	I understand the hand hygiene policy of my workplace	0	3.8	0	22.9	73.3	4.66 ± 0.67
5	I do hand hygiene out of concern for my residents	1.7	7.6	0	24.6	66.1	4.46 ± 0.96
6	Hand hygiene is important because I have contact with many Patients	1.7	3.4	0	18.3	76.6	4.65 ± 0.8
7	Hand hygiene is an important part of my job	0	16.7	0	83.3	0	3.67 ± 0.75
8	I feel guilty if I don’t do hand hygiene	0	17.9	0	82.1	0	3.64 ± 0.77
9	Hand hygiene is an important part of my professional training	0	14.7	0	85.3	0	3.71 ± 0.71
10	Hand hygiene prevents the spread of infection	1.7	4.0	0	16.1	78.2	4.65 ± 0.82
11	The non-urgent needs of my patients take priority over doing hand hygiene	10.6	11.3	0	22.2	56.0	4.02 ± 1.4
12	Hand hygiene prevents me from getting infections from contaminated surfaces	0	17.1	0	82.9	0	3.66 ± 0.76

Statistical analysis

Descriptive statistics were used to summarize the respondents' demographics, perceived knowledge, and attitudes. Inferential statistics were used to explore the relationships between variables and discover predictors of hand hygiene compliance. Logistic and multiple regression were utilized to investigate the relationship and association between included variables. The quantitative data from the survey questionnaire was analyzed using the IBM SPSS v.28 software (IBM Corp., Armonk, NY, USA); URL link. https://www.ibm.com/spss.

Results

Descriptive findings overview

Of the 680 distributed questionnaires, a total of 600 HCWs completed the study (response rate 88%). Table 1 presents the respondent's demographic characteristics, including their profession, sex, years of experience in healthcare, direct care provision to patients, perceived hand hygiene knowledge, previous hand hygiene training, history of HAIs, as well as perceived job workload. The majority of HCWs in our study were females (75.1%) and nurses (50%). Additionally, 78% of respondents had at least a year’s experience, 71% had previously received training on hand hygiene, 93% evaluated their understanding of hand hygiene as good, and around 70% indicated managing their workload was challenging.

Hand hygiene knowledge

Most respondents (93%) reported having good hand hygiene knowledge. However, there was variation in the level of knowledge on hand hygiene. Compared to male respondents, more female respondents (β = 0.14, p < 0.001) indicated they have good hand hygiene knowledge. Furthermore, the knowledge of respondents who had previously received hand hygiene instruction was greater (β = 5.57, p < 0.05) compared to respondents who did not receive any hand hygiene training.

Prior hand hygiene training

A majority of respondents (71%) stated that they had received previous training in hand hygiene. Comparing the respondents, we found that more female respondents than male respondents reported having had prior hand hygiene training (β = 3.39, p < 0.001). Furthermore, compared to all other professions, a higher percentage of nurses reported having previous training in hand hygiene (β = 7.76, p < 0.001).

History of HAI infection

The percentage of responders who have been infected due to HAI was high (60%). Respondents with high workloads were more likely to report hospital-associated infections (β = 1.58, p < 0.05). Additionally, respondents who had experienced HAIs were more likely to report having hand hygiene training (β = 6.171, p < 0.001).

Attitudes toward hand hygiene

In the examination of the attitudes of ICU HCWs regarding hand hygiene (Table 2), a considerable majority had a good overall attitude toward hand hygiene (M = 4.15, SD = 0.85). One-third of the respondents disagreed that hand hygiene is a crucial aspect of their work, while 18% said they would not feel guilty if they disregarded hand hygiene regulations. Additionally, 17% of the respondents thought hand hygiene would not stop infections from contaminated surfaces, 4% said they were unaware of their employer’s hand hygiene policy, and 6% disagreed that hand hygiene can help spread infection.

The multiple linear regression model

The multiple linear regression model examined how the healthcare profession, sex, years of experience, direct patient care, hand hygiene knowledge, previous hand hygiene training, past HAI experience, and perceived workload influenced attitudes toward hand hygiene (Table 3). The suggested model explains around 15% of ICU respondents' attitudes towards hand hygiene, as indicated by an adequate fit (F (583) = 6.05, p < 0.001) and R² = 0.15. The model identified significant associations between respondents’ attitudes toward hand hygiene and perceived knowledge about hand hygiene (β = 0.32, p < 0.001), previous training in hand hygiene practices (β = 0.13, p < 0.05), and having experience, less than a year of experience compared to more than 10 years of experience (β = − 0.10, p < 0.05), and being a physician compared to being a nurse (β = − 0.07, p < 0.05).

Table 3.

Regression of perceptions and attitudes towards hand hygiene.

Variables	Categories	Standardized coefficients (β)	95% confidence interval for β		p-value
			Lower bound	Upper bound
Healthcare profession category (Nurse)	Laboratory Specialist	0.03	− 0.05	0.10	0.50
	Pharmacist	0.32	− 0.06	0.09	0.74
	Physical therapist	0.04	− 0.03	0.13	1.113
	Physician	− 0.07	− 0.15	− 0.01	0.04*
	Radiology Therapist	− 0.02	− 0.11	0.05	0.55
	Respiratory Therapist	0.01	− 0.06	0.09	0.71
	Other	0.13	− 0.10	0.12	0.88
Sex (Male)		0.06	− 0.02	0.14	0.15
Years of experience in healthcare (More than 10 years)	Less than 1 year	− 0.092	− 0.18	− 0.01	0.04*
	1–5 years	− 0.03	− 0.11	0.04	0.41
	6–10 years	0.01	− 0.07	0.10	0.73
Do you provide direct care to patients (Yes)		0.081	− 0.02	0.18	0.13
How would rate your hand hygiene knowledge (Good)		0.32	0.24	0.40	< 0.001*
Have you had any previous hand hygiene training from the infection control department (Yes)		0.11	− 0.22	− 0.01	0.03*
Have you experienced any hospital-associated infections before (Yes)		0.04	− 0.04	0.12	0.38
How would you describe your workload in the hospital (manageable)		0.01	− 0.07	0.10	0.74

Discussion

The current study aims to explore the attitudes of ICU HCWs toward hand hygiene and determine the associations between such attitudes and HCWs' knowledge of hand hygiene, prior hand hygiene training, history of HAIs, perceived workload, and HCWs’ demographic factors. We found that most respondents had a good overall attitude toward hand hygiene that was correlated positively with the respondent’s knowledge and training on hand hygiene. In addition, physicians exhibited lower attitudes than nurses, while HCWs with less than 1 year of experience reported lower attitudes than more experienced HCWs.

We found that hand hygiene knowledge was high among the majority of participants. Similar findings have been demonstrated by other studies¹⁶. However, non-compliance with hand hygiene was not necessarily related to hand hygiene knowledge among healthcare workers¹⁷. Compared to male HCWs, more female HCWs in our study reported knowing a lot about hand hygiene. Other research demonstrated similar findings in Saudi Arabia¹⁸, and in other countries^19,20. No clear rationale has been provided; therefore, additional quantitative and qualitative studies are necessary to throw more light on such gender discrepancies. We also identified a positive correlation between prior training in hand hygiene and perceived hand hygiene knowledge among HCWs. As a result, training healthcare staff on proper hand washing techniques and providing them with reminders may greatly increase their awareness and proficiency regarding hand hygiene²¹.

In our study, although it was more common among women, the majority of respondents had received some form of hand hygiene training in the past. Such findings are in contrast with other studies that showed no significant difference¹⁷. Additionally, we observed that more nurses reported having hand hygiene training compared to other professions. Other studies have found that nurses receive greater training in hand hygiene practices than physicians and other healthcare workers²¹. The increased level of training among nurses might be justifiable considering the frequency of direct contact with the patient in the ICU. Thus, hospital management should routinely schedule essential training programs, praise, and reward HCWs for meeting established objectives and ensuring patient care and safety.

We found that most of the respondents had a history of HAIs, which was shown to be positively associated with the amount of work they performed. It should be noted that the development of HAI combined with the inherent complexity of care for ICU patients can directly impact HCWs and cause work overload, which might contribute to the increase of HAIs⁵. Despite other patient-related and procedure-related variables, an excessive workload for healthcare workers was found to be a major risk factor for the development of HAIs in clinical patients admitted to the ICU^9,22,23.

The examination of the attitudes of the participants regarding hand hygiene reveals that a significant majority displayed a positive overall attitude toward hand hygiene. The participant's attitude toward hand hygiene was high compared to other research that revealed HCWs' moderate to poor attitudes^15,24,25. Studies have demonstrated that the positive attitude of healthcare personnel is associated with an increase in hand-washing behaviors^26,27. As a result, establishing educational programs will play an important role in boosting HCW's attention and good attitudes about hand washing practices, as well as standardizing health habits to promote hand hygiene^6,28,29.

The findings of our research indicate that most of the items in the attitude construct demonstrated a favorable attitude toward hand hygiene. However, more emphasis was placed on predicting oneself compared to others (i.e. patients). Such results have been shown in other research³⁰. For instance, HCWs were shown to be more inclined to participate in self-protective procedures for hand hygiene (e.g., after being exposed to bodily fluid, after patient interaction) than patient-protective activities (e.g., before an aseptic task)^5,31. Therefore, efforts can be undertaken to shift the emphasis away from a protecting oneself exercise to an activity that benefits oneself and others to enhance HCWs’ attitudes and adherence³².

Our study findings indicate that physicians exhibit a diminished percentage of positive attitudes compared to nurses, potentially due to many underlying factors. For instance, training initiatives might largely target nurses, with doctors and other HCWs either infrequently included or overlooked^33,34. Moreover, nurses are far more compliant than doctors, and doctors have been shown to have improper attitudes regarding hand hygiene, believing there is insufficient evidence to support the use of hand cleanliness in preventing HAIs^35,36.

This study has some limitations. First, practicing good hand hygiene is a socially valued activity. As a result, respondents may overestimate their conduct. Future research might use alternative objective ways to achieve more reliable evaluations. Second, although self-reports are the simplest approach to collecting data on hand hygiene attitudes, they might introduce bias owing to cognitive and psychological variables. Third, this study used a random sample from the Riyadh region, limiting the generalizability of the findings.

Conclusion

Hand hygiene emerges as a fundamental measure in infection control, serving as a critical bridge between HCWs, patients, and pathogens. HAIs present a significant and complex challenge in the realm of global healthcare, with Saudi Arabia being no exception. This study was conducted to better understand the attitudes of HCWs toward hand hygiene and to examine potential predictors that influence such attitudes. We found that HCWs in the ICU had an average high attitude toward hand hygiene. Such attitudes were correlated with hand hygiene knowledge, previous training, and job experience. The findings underscore the multifaceted nature of hand hygiene attitudes. By addressing individual, organizational, and environmental factors, healthcare institutions in Saudi Arabia can foster a culture of hand hygiene, ultimately contributing to the reduction of HAIs and improving patient safety. In addition, certain populations or healthcare settings may obtain more benefits from certain procedures or combinations of treatments compared to others. Therefore, the healthcare organization’s involvement should be tailored to meet local needs and use available resources accordingly.

Author contributions

NA and SS collecred the data wrote the main manuscript text. All authors reviewed the manuscript.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Competing interests

The authors declare no competing interests.