Abstract
Background:
Hand hygiene is a core component of infection prevention in healthcare settings. One potential reason for lack of adherence to recommended hand hygiene practices is erroneous self-perception. We aimed to compare perceptions about hand hygiene compliance with objective data.
Methods:
Direct observations of hand hygiene performance by nurses and physicians during typical workflow in inpatient general medicine wards were conducted from 12 September 2022 to 27 October 2022 at two academic Veterans Affairs medical centers. Participants were surveyed regarding perceptions about their hand hygiene performance relative to recommended practices.
Results:
Among nurses, hand hygiene was performed in 1,397 / 3,690 (37.9%) room entry and 2,159 / 4,102 (53.8%) room exit opportunities (combined adherence, 46.2%). For physicians, hand hygiene was performed in 1,016 / 1,237 (82.1%) room entry and 1,073 / 1,285 (83.5%) room exit opportunities (combined adherence, 82.8%). Surveys were collected from 92 / 161 nurses (57.1%) and 189 / 294 physicians (64.3%). Nurses self-reported compliance in 95.1% of recommended situations, while physicians self-reported 91.0%.
Conclusions:
We found a disconnect between actual and perceived adherence to hand hygiene recommendations among bedside nurses and physicians in inpatient general medicine wards. This disconnect may be due to social desirability, self-serving, or overestimation biases, or time pressures. Awareness of such a disconnect may help policymakers increase hand hygiene rates.
Keywords: Hand hygiene, adherence, infection prevention, nurse, physician
Introduction
Performing hand hygiene is a core infection control measure. Prior literature has described the importance of hand hygiene in healthcare settings and its association with decreased risk of nosocomial infections and transmission of infectious pathogens.1, 2 National hand hygiene guidance was first released during the 1980’s, and in 2002, the U.S. Centers for Disease Control and Prevention (CDC) made comprehensive universal recommendations regarding hand hygiene in healthcare settings.3 Hand hygiene is recommended at five defined moments by the World Health Organization (WHO). These include: (1) before touching a patient; (2) before performance of a clean or aseptic procedure; (3) following exposure to a patient’s body fluids; (4) after touching a patient; and (5) after touching patient surroundings.4 Guidance from the CDC includes these recommendations and several others, including recommendations related to hand hygiene technique, selection of hand hygiene agents, and hand hygiene performance indicators.3 Because a person entering a patient’s room might not necessarily know if they will need to touch the patient or surroundings while in the room, some hospitals recommend hand hygiene every time healthcare personnel enter or leave a patient’s room.
Barriers to hand hygiene adherence among clinicians include insufficient time or staffing, urgent patient-care needs, workflow, and a need to repeatedly perform hand hygiene over a brief period of time.3 Previous studies have explored the impact of behavioral interventions on adherence to hand hygiene recommendations.3, 5, 6 In 1998, a comprehensive hypothetical framework for enhancing adherence to hand hygiene guidelines was proposed.7 The framework included organizational and individual-level factors (such as organizational beliefs and values and individual readiness for behavioral change or modification, respectively) which are related to hand hygiene adherence.
A specific concept in this topic area is the simultaneous comparison of direct, in-person hand hygiene observations to self-reported perceptions of hand hygiene adherence. A prior study of nurses conducted in Japan showed that there was a substantial gap between self-evaluation of hand hygiene compliance compared with actual compliance rates when directly observed.8 However, this study did not include physicians, demographic information about participants was not included, and duration of hand hygiene was not reported. Another study conducted in Germany evaluated the relationship between hand hygiene compliance measured through observation and self-report and clinician empathy.9
Because hand hygiene is performed so often, even outside of the healthcare setting, it is possible that clinicians’ mental beliefs about their adherence to hand hygiene guidelines differs from what they are actually doing, which could potentially limit the impact of individual-level behavioral interventions to increase hand hygiene adherence rates. Overconfidence related to hand hygiene was previously evaluated in a survey study that suggested healthcare workers believe they are better than average with regard to infection prevention tasks.10 Prior work has also demonstrated a lack of statistically significant correlations between theoretical hand hygiene knowledge and actual hand hygiene performance, with high levels of knowledge not translating to optimal actual performance.11
To our knowledge, a detailed comparison between self-reported and observed hand hygiene adherence among nurses and physicians has not been conducted in the United States. Additionally, more detailed views about the importance of hand hygiene and perceptions about hand hygiene are not well-established. The purpose of the present study was to observe hand hygiene practices among both nurses and physicians, to compare these observations with self-reported rates of adherence to hand hygiene recommendations, and to assess perceptions about hand hygiene.
Methods
Study design and participants
We conducted a prospective observational descriptive study. The study consisted of two components: direct hand hygiene observations and completion of a survey. Nurses and physicians who routinely worked in the relevant inpatient nursing units were observed for hand hygiene performance, regardless of whether they participated in the survey portion of the study. Hand hygiene observations were conducted from 12 September 2022 through 27 October 2022. Surveys were collected from 8 November 2022 through 23 January 2023 for nurses and from 16 February 2023 through 23 April 2024 for physicians.
The study was conducted at two large, geographically distinct Veterans Affairs (VA) academic medical centers. Medical Center 1 is a tertiary-care facility with ~100 acute-care beds, ~16 intensive-care unit (ICU) beds, 40 subacute rehabilitation (SAR) beds, and an Emergency Department. Medical Center 2 is a tertiary-care facility with ~350 acute-care beds, ~30 ICU beds, ~140 nursing-home beds (with a mixture of SAR and long-term care), and an Emergency Department.
Participants in this study were bedside registered nurses and physicians. Nurses eligible for inclusion in the study were those who worked on two specific inpatient general medicine acute care wards in Medical Center 1and four similar wards in Medical Center 2. Physicians eligible for inclusion in the study were attendings and resident trainees who were assigned to work on inpatient general medicine teams during the timeframe of the study. Medical students were excluded from participation. Participants included in the survey were recruited in person and via a standardized e-mail from study staff.
Data-collection instruments
The survey assessed participants’ perceptions of their hand hygiene adherence, based on questions selected from the Perceptions Survey for Healthcare Workers developed by the World Health Organization.12 The section of the survey focusing on clinicians’ perceptions and beliefs on hand hygiene is provided in Appendix 1. Three of the questions are ranked on a 4-point Likert scale (1 - very low importance to 4 - very high importance), four are ranked on a 7-point Likert scale (1 - no importance to 7 - high importance), and one question asked for a self-rated percentage of situations where hand hygiene was believed to be performed (0-100%). Prior studies using this questionnaire have demonstrated good internal consistency and Cronbach’s alpha scores, indicating strong reliability.
Procedures
Hand hygiene observations of bedside nurses were made during their normal workflow during day and night shifts in a total of six inpatient general medicine nursing units by trained study staff. Written step-by-step instructions to standardize observation procedures were reviewed with study staff prior to conducting observations. The frequency of hand hygiene performance, either with alcohol-based hand rub (ABHR) or soap and water, was directly observed during entry to and exit from patient rooms, which were considered the two observable hand hygiene opportunities. Observers also timed the duration of hand hygiene at room exit using a handheld stopwatch. Successful hand hygiene was considered to be any attempt at performing hand hygiene, regardless of the duration for which it was done. A duration of 0 seconds was recorded if a clinician applied ABHR but then immediately touched another object without having rubbed for any period of time. The use of gloves by clinicians did not impact the assessment of hand hygiene performance, which was considered independently of glove use. Observers were positioned in discreet locations on the units such that they did not draw attention to the observation process or impact routine delivery of patient care. Because the discreet locations were outside patient rooms, observers did not have the opportunity to fully view activities inside patient rooms. However, ABHR dispensers were located on the walls outside of patient rooms. Additionally, if an observer was able to see (from their discreet location) a clinician performing hand hygiene using soap and water inside of a patient’s room, hand hygiene adherence was recorded.
Hand hygiene observations of physicians were also made during their normal workflow in the same six inpatient general medicine nursing units. Physicians were typically observed during team rounds, which were usually conducted in the morning and involved attending physicians and residents. As with the nurses, physician observations were performed discreetly without observers drawing attention to themselves. Observations were aggregated to track hand hygiene adherence among all hand hygiene opportunities observed. The total numbers of unique nurses and physicians observed and the extent to which observations were conducted on the same clinician were not specifically tracked. Hand hygiene observations were not restricted to clinicians completing surveys.
Participants in the survey portion of the study were provided a paper survey (with a return envelope) to complete. If preferred, an Internet web link was also provided for electronic completion of the survey. Nurses who received the survey were among the pool of nurses observed for hand hygiene. Because physicians were rounding in the units only during assigned clinical rotations, it is possible that some physicians surveyed might not have been included in the hand hygiene observations, which were conducted prior to survey administration. Additionally, hand hygiene observations for both physicians and nurses were anonymous and therefore could not be linked directly to individual survey responses.
Ethical considerations
This study was approved by the United States Department of Veterans Affairs Central Institutional Review Board Office as protocol number 1630589 on 5 November 2021. Hand hygiene observations were conducted with a waiver of informed consent. Participants provided written informed consent to participate in the survey portion of the study on a voluntary basis. All data were maintained on secure approved servers in a confidential manner.
Data analysis
Baseline demographic information about participants, including age, sex, and race/ethnicity, were collected. Descriptive statistics on demographic characteristics, baseline hand hygiene observations (adherence and duration), and survey elements assessing perceptions surrounding appropriate hand hygiene practices were obtained for nurses and physicians. Respondents were allowed to skip questions resulting in slightly smaller sample sizes for some responses. Missing data was minimal, and data imputation was not conducted. Means and standard deviations were estimated for continuous variables, and percentages were calculated for categorical variables. Comparisons by clinician role for observed hand hygiene compliance and duration were calculated using Chi-square tests and two-sided t-tests, respectively. For comparisons of hand hygiene perception questions assessed on Likert scale responses, we used t-tests with Welch approximations. A p-value of less than .05 was considered statistically significant for all tests. All analyses were performed in SAS 9.4 (SAS Institute Inc., Cary NC) and Stata SE 18.5 (StataCorp, College Station, TX).
Results
Participants
The nursing units which participated in the study employed 161 nurses at the start of the study. Among these, 93 (57.8%) participated in the survey. One survey was incomplete, resulting in a final sample of 92 nurse surveys. A total of 88 nurses answered the question asking clinicians to self-rate the average percentage of situations requiring hand hygiene that they actually conduct hand hygiene. Demographic information for nurse respondents is provided in Table 1. Approximately one-third of respondents had been a nurse for more than 20 years, 46.6% were Asian, and 8.0% were Hispanic.
Table 1.
Demographic Information about Survey Participants
| Nurses | Physicians | ||
|---|---|---|---|
| N (%) | N (%) | ||
| Years in Role (N=92) | Years in Role (N=189) | ||
| 0-5 | 15 (16.3) | 0-5 | 155 (82.0) |
| 6-10 | 19 (20.7) | 6-10 | 17 (9.0) |
| 11-15 | 14 (15.2) | 11-15 | 8 (4.2) |
| 16-20 | 14 (15.2) | 16-20 | 2 (1.0) |
| More than 20 | 30 (32.6) | More than 20 | 7 (3.7) |
| Age (N=91) | Age (N=189) | ||
| 18-24 | 1 (1.1) | 18-24 | 1 (0.5) |
| 25-34 | 14 (15.4) | 25-34 | 148 (78.3) |
| 35-44 | 20 (22.0) | 35-44 | 26 (13.8) |
| 45-54 | 37 (40.7) | 45-54 | 7 (3.7) |
| 55 or older | 19 (20.9) | 55 or older | 7 (3.7) |
| Race (N=88) | Race (N=187) | ||
| White | 16 (18.2) | White | 121 (64.7) |
| Black or African American | 21 (23.9) | Black or African American | 4 (2.1) |
| Asian | 41 (46.6) | Asian | 48 (25.7) |
| Other | 10 (11.4) | Other | 14 (7.5) |
| Ethnicity (N=88) | Ethnicity (N=189) | ||
| Hispanic/Latino | 7 (8.0) | Hispanic/Latino | 15 (7.9) |
| Sex (N=91) | Sex (N=189) | ||
| Men | 8 (8.8) | Men | 109 (57.7) |
| Women | 83 (91.2) | Women | 130 (42.3) |
| Role (N=189) | |||
| Attending | 59 (31.2) | ||
| Resident | 130 (68.8) | ||
A total of 191 physicians participated in the survey portion of the study. Two surveys were incomplete, resulting in a final sample of 189 physician surveys. Demographic information for physician respondents is also available in Table 1. Slightly less than one-third of physicians who completed the survey were attendings, 57.7% were men, 64.7% were White, and 7.9% were Hispanic.
Hand hygiene observations
Hand hygiene observations were conducted for a total of 402 hours over 33 days. These observations included 332 hours during daytime shifts (7:30 AM to 7:30 PM) and 70 hours during nighttime shifts (7:30 PM to 7:30 AM). Hand hygiene on room entry was performed more frequently by physicians (1,016 of 1,237 [82.1%] room entry opportunities) than nurses (1,397 of 3,690 [37.9%] room entry opportunities) (p < .001). Similarly, hand hygiene on room exit was performed more frequently by physicians (1,073 of 1,285 [83.5%] room exit opportunities) than nurses (1,397 of 3,690 [37.9%] room entry opportunities) (p < .001). Overall, hand hygiene was performed by physicians for a total of 2,089 of 2,522 (82.8%) opportunities, compared to a total of 3,556 of 7,702 (46.2%) opportunities among nurses. These results are summarized in Table 2.
Table 2.
Observed Adherence and Mean Duration of Hand Hygiene upon Room Entry and Exit
| Hand Hygiene Adherence | ||||
|---|---|---|---|---|
| Nurses N (%) |
Physicians N (%) |
Chi-square | P-value | |
| Hand Hygiene on Room Entry | ||||
| Total hand hygiene opportunities | 3690 | 1237 | 726.73 | <0.001 |
| Yes | 1397 (37.9) | 1016 (82.1) | ||
| No | 2293 (62.1) | 221 (17.9) | ||
| Hand Hygiene on Room Exit | ||||
| Total hand hygiene opportunities | 4012 | 1285 | 360.64 | <0.001 |
| Yes | 2159 (53.8) | 1073 (83.5) | ||
| No | 1853 (46.2) | 212 (16.5) | ||
| Hand Hygiene Duration | ||||
| Nurses | Physicians | t-value | P-value | |
| Total hand hygiene observations | 2091 | 246 | ||
| Mean Duration of Hand Hygiene on Room Exit (Standard Deviation) (sec) | 8.3 (7.3) | 12.9 (8.6) | −8.09 | <0.001 |
For nurses, mean duration of hand hygiene at room exit was 8.3 seconds (standard deviation [SD] 7.3 seconds). The range of hand hygiene duration at room exit was 0 to 60.0 seconds with 18 observations being censored at 60.0 seconds. For physicians, mean duration of hand hygiene at room exit was 12.9 seconds (SD 8.6 seconds). The range of hand hygiene duration at room exit was 0 to 60.0 seconds with 21 observations censored at 60.0 seconds. The most common form of hand hygiene used was ABHR, which represented 95.1% of hand hygiene occurrences for nurses and 99.7% for physicians. Soap and water were employed infrequently at both sites by physicians at room entry (0.1%) and room exit (0.8%), and by nurses at room entry (0.6%). Nurses at Medical Center 1 did not regularly use soap and water on room exit (0.5%). However, soap and water were used by nurses at Medical Center 2 at room exit 15.5% of the time.
We noted a discrepancy regarding hand hygiene adherence among different physician roles (Table 3). At room entry, hand hygiene was performed more frequently by attending physicians (87.9%) as compared to senior residents (82.0%) and interns (79.8%) (Chi-square statistic = 8.74, p = .01). Hand hygiene adherence at room exit did not differ significantly by physician role (attendings [86.3%], senior residents [82.5%], and interns [82.7%]; Chi-square statistic = 2.24, p = .33).
Table 3.
Observed Hand Hygiene Adherence by Type of Physician
| Attending | Senior Resident | Intern | Chi-square | P-Value | |
|---|---|---|---|---|---|
| N (%) | N (%) | N (%) | |||
| Hand Hygiene on Room Entry | |||||
| Yes | 246 (87.9) | 241 (82.0) | 529 (79.8) | 8.74 | .01 |
| No | 34 (12.1) | 53 (18.0) | 134 (21.2) | ||
| Hand Hygiene on Room Exit | |||||
| Yes | 253 (86.4) | 260 (82.5) | 560 (82.7) | 2.24 | .33 |
| No | 40 (13.7) | 55 (17.5) | 117 (17.3) |
Survey results
The average percentage of the time survey respondents believed they performed hand hygiene in situations in which it is recommended was higher among nurses compared to physicians (nurses – 95.1% (SD 7.2%, 95% CI: 93.6%–96.7%]; physicians – 91.0% [SD 11.1%, 95% CI: 89.4%–92.6%], p < .001). A total of 42 of 88 (47.7%) nurse respondents reported this number to be 100%. A total of 42 of 188 (22.3%) physician respondents reported this number to be 100%.
Among nurse respondents, 79 of 92 (85.9%) noted that effectiveness of hand hygiene in preventing healthcare-associated infections is “very high,” whereas 108 of 189 (57.1%) physicians gave this rating (4-item Likert mean comparison – nurses 3.86 (95% CI: 3.79–3.93); physicians 3.52 (95% CI: 3.44–3.61), p < .001). On a scale from 1 (no importance) to 7 (very high importance), a total of 67 of 91 (73.6%) nurses and 50 of 189 (26.5%) physicians reported that their colleagues attach very high importance to the respondent’s performance of optimal hand hygiene (7-item Likert mean comparison – nurses 6.51 (95% CI: 6.30–6.71); physicians 5.29 (95% CI: 5.08–5.50), p < .001). Similarly, a total of 56 of 91 (61.5%) nurses and 44 of 189 (23.3%) physicians described that patients attach very high importance to the respondent’s performance of optimal hand hygiene (7-item Likert mean comparison – nurses 6.10 (95% CI: 5.81–6.39); physicians 4.99 (95% CI: 4.77–5.21), p < .001). Finally, a total of 63 of 92 (68.5%) nurses and 29 of 189 (15.3%) physicians responded that performing good hand hygiene required substantial effort (7-item Likert mean comparison – nurses 5.86 (95% CI: 5.43–6.28); physicians 3.78 (95% CI: 3.47–4.09), p < .001).
Discussion
Our multi-site study found that actual adherence to hand hygiene recommendations was 46.2% for nurses and 82.8% for physicians, with higher adherence noted at room entry for attending physicians (88%) as compared to interns (80%). In contrast to the observed findings of hand hygiene adherence, our survey indicated that nurses believe they perform hand hygiene in approximately 95% of instances in which it is recommended, with nearly half of respondents believing that number to be 100%. Physicians believe that they perform hand hygiene in approximately 90% of instances in which it is recommended. These findings reveal an important disconnect between actual and perceived adherence to hand hygiene recommendations among bedside nurses in general medicine wards at two geographically distinct academic VA medical centers. Additionally, the finding that attendings had higher adherence to hand hygiene recommendations as compared to interns and senior residents suggests differential emphasis on this particular patient safety intervention, which might be due to varying behavioral factors on the treatment team.
Appropriate and consistent hand hygiene can prevent healthcare-associated infection. Despite this, hand hygiene adherence among clinicians is variable and remains suboptimal. A previous systematic review suggested that adherence to hand hygiene was approximately 40% across all settings and types of clinicians and approximately 50-60% in acute care wards.13 This same systematic review described that adherence to hand hygiene recommendations is higher after patient contact (median compliance rate of 47% across studies) than prior to patient contact (median compliance rate of 21% across studies).13 We noted a similar trend in our study among nurses, with adherence to hand hygiene being higher at room exit than entry. Additionally, we found that the mean duration for which hand hygiene was performed was approximately 8 seconds for nurses and 13 seconds for physicians. These findings are consistent with findings from prior observational studies, which have demonstrated a mean duration of hand hygiene lasting 6.6-24.0 seconds.3 Importantly, a 15-second duration of hand hygiene is recommended by the CDC if washing hands with soap and water.3 Although no specific duration of hand hygiene is recommended when ABHR is used,3 guidelines indicate rubbing hands and fingers together until dry, which should take around 20 seconds.14
Possible explanations for this constellation of findings and the discrepancy between actual and perceived adherence to hand hygiene recommendations include social desirability bias, self-serving bias, and overestimation bias when answering survey questions, the need for multiple trips into and out of patients’ rooms to access medications or supplies located outside the room, and time pressures.3
Social desirability bias refers to the concept that survey respondents will enter answers which they believe will portray them favorably among their peers or with those administering a survey.15 In doing so, they may withhold their authentic opinions or viewpoints. In this instance, indicating lower hand hygiene frequency than recommended might be considered socially undesirable. Self-serving bias (which maintains psychological integrity and does not serve social purposes) in this instance may stem from respondents often overestimating their hand hygiene performance compared to peers and attributing failures to other external factors (e.g., lack of hand hygiene product availability).16 Overestimation bias, one of the forms of overconfidence bias, refers to the tendency of people to incorrectly assess their skill level in performing a particular task.17
Additionally, it is possible that the five moments of hand hygiene as recommended by the WHO do not fit well with typical workflow for nurses on an acute care ward. This might explain the difference observed in hand hygiene adherence between nurses and physicians. The complexity of the typical adult inpatient has increased over time.18 It is possible that multiple trips into and out of patients’ rooms are needed to access medications or supplies located outside of the room. It is also possible that in some instances when nurses enter a patient’s room, they will not necessarily be touching either the patient or the patient’s immediate surroundings. In such instances, the nurse may feel that hand hygiene is not necessary due to low risk of becoming colonized with an infectious pathogen. Additionally, nurses have substantially more opportunities for hand hygiene than physicians, making it somewhat easier for physicians to have higher levels of adherence to the recommendations.
Importantly, it is worth noting that unexpected contact may occur even if the clinician entered the room without a clear intention to touch the patient or their surroundings. When hand hygiene is recommended upon entry and exit from the room, this is based on the assumption that there will be direct clinician-patient interaction, but it is not explicitly known what a clinician does during each entry into a patient’s room. A prior study evaluated hand hygiene adherence as assessed at room entry and room exit versus assessment at each of the five moments of hand hygiene as recommended by WHO and found comparable rates of hand hygiene adherence.19 This study also found that approximately a quarter of the time when a clinician entered a room, there was not necessarily any specific contact with the patient or environment.19
Patient complexity and the frequency of patient encounters are also directly related to a ubiquitous concern in modern healthcare, namely time pressures faced by busy clinicians. The phenomenon of heightened time pressures likely also extends to bedside nurses through both complexity and volume. A study from 2012 linked patient-to-nurse ratios with higher rates of urinary tract infections and surgical site infections.20 While adhering to hand hygiene recommendations as an intermediary step was not explicitly examined in the study, it is a plausible contributing factor because of less time available per patient for patient care activities. A substantial amount of time would be spent if hand hygiene is performed for 15 seconds at each recommended opportunity with 100% fidelity. If time is limited, eschewing or curtailing hand hygiene might be a practical (and perhaps even unconscious) response. This interpretation is supported by our survey finding that approximately double the proportion of nurses as physicians (83% versus 41%) felt that performance of optimal hand hygiene required significant effort.
Strengths and limitations
Strengths of our study include its multi-site design and large number of participants and hand hygiene observations, which increase the generalizability of findings. Additionally, this study was one of the first to directly assess self-perceptions of hand hygiene adherence among nurses and physicians in the United States.
We also note several limitations. First, the presence of observers monitoring hand hygiene adherence may have led to the Hawthorne effect, in which those being observed tend to be more compliant because they know they are under observation. Such an effect would have biased the results toward the appearance of higher adherence than the true rate. Second, the reason why observed clinician adherence to hand hygiene was lower than self report was not directly assessed through questioning. Third, clinician behaviors that occurred within the patients’ rooms were not fully accessible to observers because the observers remained outside and often had limited views. Instead, observations of hand hygiene were conducted at room entry and exit. As such, information about patient contact or contact with immediate surroundings are unknown. Many sinks were located within patient rooms, which may have limited our ability to observe hand hygiene performed with soap and water. Fourth, a series of single-answer questions were used to assess clinician perceptions of hand hygiene. While this approach can potentially be less reliable than multi-item scales, we maintained the single-answer format utilized by the Perception Survey for Healthcare Workers questionnaire. Finally, the nurses and physicians who responded to the survey might not necessarily have been the same as those who were observed for hand hygiene adherence, although we expect many were due to the timing of our surveys and observations.
Overall, our study demonstrated a marked disconnect between actual hand hygiene adherence and self-reported perceptions of adherence among nurses and (to a lesser extent) physicians working on general medicine units at two medical centers. This work suggests that future educational efforts toward hand hygiene adherence might benefit from a focus on overcoming cognitive biases, including the need to emphasize safety culture and ongoing feedback to clinicians. Improved hand hygiene adherence would help achieve the health policy objective of minimizing healthcare-associated transmission of infectious diseases as much as possible. This study could also provide evidence that typically recommended moments of hand hygiene pose practical challenges for nurses providing complex care requiring frequent and recurrent patient contact in modern hospitals.
Supplementary Material
Acknowledgements
Financial support: This work was supported by the Department of Veterans Affairs Office of Research and Development (grant number HSR IIR 19-097). BWT’s work is supported in part by VA Health Systems Research CIN 13-413.
Footnotes
Conflicts of interest: None of the authors have any conflicts of interest to disclose.
Disclaimer: This work does not necessarily represent the views of the United States Government or the Department of Veterans Affairs.
Artificial intelligence use: No artificial intelligence (AI) technology was used for any part of this study, including manuscript preparation or revision.
Previous Publication: Some findings described in this manuscript were presented in preliminary form as a poster abstract at the IDWeek conference in Los Angeles, California, in October 2024.
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Associated Data
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