Patient Safety Issues

B EHAVIORAL
DETERMINANTS OF HAND
HYGIENE COMPLIANCE IN
INTENSIVE CARE UNITS
By David De Wandel, RN, MSc, Lea Maes, PhD, Sonia Labeau, RN, MNSc, Carine
Vereecken, PhD, and Stijn Blot, PhD

Background Although hand hygiene is the most effective

measure for preventing cross-infection, overall compliance is
poor among health care workers.
Objectives To identify and describe predictors and determi-
nants of noncompliance with hand hygiene prescriptions in

C E 1.0 Hour
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A closed-book, multiple-choice examination
following this article tests your understanding of
the following objectives:
1. Recognize the impact of behavioral determi-
nants on compliance with hand hygiene rec-
ommendations.
2. Describe determinants of noncompliance
with hand hygiene prescriptions among
nurses in a general intensive care unit.
3. Understand how a low self-efficacy and a
negative attitude toward time-related barriers
are predictors of poor compliance with hand
hygiene recommendations.
To read this article and take the CE test online,
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©2010 American Association of Critical-Care Nurses
doi: 10.4037/ajcc2010892
intensive care unit nurses by means of a questionnaire.
Methods A questionnaire based on a behavioral theory model
was filled out by 148 nurses working on a 40-bed intensive
care unit in a university hospital. Subjects were asked to fill
out the 56-item questionnaire twice within a 2- to 6-week
period. During this period, no interventions to enforce hand
hygiene occurred on the unit.
Results Response rate for the test was 73% (108/148); response
rate for the retest was 53% (57/108). The mean self-reported
compliance rate was 84%. Factor analysis revealed 8 elemen-
tary factors potentially associated with compliance. Internal
consistency of the scales was acceptable. Intraclass correla-
tion was low (<0.60) for 2 subscales but acceptable (>0.60) for
6 subscales. A low self-efficacy was independently associated
with noncompliance (β = .379; P = .001). After exclusion of this
variable, a negative attitude toward time-related barriers was
associated with noncompliance (β = -.147; P < .001).
Conclusions Neither having good theoretical knowledge of
hand hygiene guidelines nor social influence or moral per-
ceptions had any predictive value relative to hand hygiene
practice. A valid questionnaire to identify predictors and
determinants of noncompliance with hand hygiene has been
designed. Nurses reporting a poor self-efficacy or a poor atti-
tude toward time-related barriers appear to be less compliant.
(American Journal of Critical Care. 2010;19:230-240)

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A
lthough hand hygiene is the most effective measure to prevent cross-infection
and as such limits the deleterious effect of health care–associated infection,1-4
overall compliance is unacceptably poor among health care workers. Barriers to
appropriate hand hygiene practice have been studied and reported extensively,
but even in settings with optimal environmental conditions, compliance appears
to range from 50% to 60% at most.1,5-9 Furthermore, few interventions seem to result in a last-
ing effect.1,5,7,10 These findings suggest that behavioral determinants such as attitude, social
influence, and self-efficacy may play a crucial role in compliance. A recent study by Whitby et al11
underlines the importance of understanding the dynamics of behavioral change in order to
design a strategy to improve hand hygiene compliance.

In accordance with the attitude–social influence–
self-efficacy model,12 which combines Fishbein and
Ajzen’s theory of reasoned action13 and Bandura’s
social learning theory,14 attitude, social influence,
and self-efficacy are valid concepts in predicting one’s
intention to change one’s behavior or even one’s
actual change in behavior.15,16
Attitude is primordially based on earlier experi-
ences: behavior that has led to success will be rein-
forced and vice versa. Although one’s general attitude
toward a certain behavior is often the result of suc-
cess and failure (or perceived advantage and disad-
vantage), not all attitudes are based on reason and
logical sense. Some attitudes can be very rigid and
based on highly irrational beliefs.
A compliment by a colleague or staff member
as a reaction on adequate hand hygiene practice
would be an example of social support on the inten-
sive care unit (ICU). Although less interactive, being
among high-compliance colleagues (ie, “role models”)
is also a common example of a positive and valuable
social influence.
About the Authors
David De Wandel and Sonia Labeau are doctoral students
in the Faculty of Health Care at University College Ghent
and Ghent University Faculty of Medicine and Health
Sciences, Ghent, Belgium. Lea Maes is a professor in
the Department of Public Health, Faculty of Medicine
and Health Sciences, Ghent University. Carine Vereecken is
a research collaborator in the Department of Public Health,
Faculty of Medicine and Health Sciences, Ghent Univer-
sity and for Research Foundation Flanders. Stijn Blot is
a research professor in the Department of General Inter-
nal Medicine and Infectious Diseases, Ghent University
Hospital and in the Faculty of Medicine and Health Sci-
ences at Ghent University.
Corresponding author: David De Wandel, University
College Ghent, Faculty of Health Care, Ghent University,
Faculty of Medicine and Health Sciences, Keramiekstraat
80, B-9000 Ghent, Belgium (e-mail: david.dewandel@
hogent.be).
Self-efficacy indicates one’s belief in one’s ability
to behave as desired and to overcome certain barriers.
In other words, self-efficacy is a person’s belief in
his or her ability to succeed in a particular situation.
Bandura17 described these beliefs as
determinants of how people think, Even in settings
behave, and feel. Behavior that proves
to be less successful or unsuccessful with optimal
will be attributed to certain causes.
Such attributions negatively influence
conditions for
self-efficacy. hand hygiene,
The first objective of this study
was to develop and validate a ques- compliance
tionnaire by which determinants of ranges from
noncompliance with hand hygiene
can be identified in ICU nurses. The 50% to 60%.
second objective was to identify and
analyze determinants of noncompliance with hand
hygiene prescriptions among nurses in a general ICU.
Methods
Questionnaire Development
Based on the literature, a questionnaire about
hand hygiene was developed, including a self-reported
compliance scale (12 items, based on the guidelines
from the Centers for Disease Control and Prevention
[CDC]18) and questions about attitudes toward hand
hygiene (12 items), social influence (10 items),
self-efficacy (10 items), and knowledge about hand
hygiene (12 items).
Knowledge. The items on the knowledge scale
were selected from a validated CDC questionnaire
on hand hygiene.18 The remaining items were con-
structed on the basis of the literature. For each item,
the respondent had to select 1 response from 4 alter-
natives. All 12 items were reviewed by an expert
panel (n = 8) that consisted of 1 microbiologist, 2
infectiologists, 3 infection control nurses, 1 inten-
sivist, and 1 researcher. As a result, some of the

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 items were slightly reworded. This method con-
tributed to the content validity. In order to obtain
an average difficulty level, all 12 items were given a
difficulty label by the experts before the question-
naire was distributed. Levels ranged from “easy” to
“quite difficult” to “difficult.”
For each correct response, the respondent
received 1 point. The sum resulted in the respondent’s
knowledge score on a scale from 0 to 12 (12 items).
Attitude, Social Influence, and Self-efficacy. The
12-item attitude scale included (1) questions on
specific advantages and disadvantages associated
with desired or undesired behavior
Knowledge of and (2) questions to determine the
respondents’ general attitude toward
hand hygiene recommended hand hygiene practice.
guidelines did not Ten items were intended to
define the social influence as experi-
predict their use. enced by the nurses and to provide
us with an answer to the following
questions: What is the ruling social norm? What is
the frequency and importance of a role model’s
presence? To what extent and in what ways are
social support and social pressure experienced by
the nurse?
Ten items were used to determine the nurses’
self-efficacy. These questions were intended to
determine crucial barriers that lead to improper
hand hygiene behavior.
All items were to be scored on a 5-point scale,
going from 1 (“I completely disagree”) to 5 (“I com-
pletely agree”). Items were constructed on the basis
of information gathered from our literature study.
Hand Hygiene Compliance. Compliance was to
be self-reported on a 5-point numeric scale, ranging
from 0% to 100% in steps of 25%. In
Nurses with poor order to include most situations in
which hand washing or disinfection
self-efficacy or a is recommended, we used an inven-
tory as suggested by the Association
negative attitude for Professionals in Infection Control
toward time /CDC17 that contains 12 different
opportunities in which hand hygiene
barriers are less is strongly recommended.
compliant. Integrity of the Knowledge Test.
In order to determine the integrity of
the knowledge test, its difficulty index and its dis-
crimination index were calculated. The difficulty
index (pi, poptimal in case of 4 answering possibilities
= 0.63, pi ranging from 0.30 to 0.70) indicates the
proportion of correct answers on a scale from 0.00
to 1.00.19
The discrimination index (d) indicates the
extent to which items on the questionnaire discrim-
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inate between high scorers and low scorers. The
following formula was used to divide respondents
into high scorers and low scorers,19 with 40% of
respondents in each group: (number of correct
answers in the high-scorer group – number of cor-
rect answers in the low-scorer group)/total num-
ber of correct answers in both groups. Items with
values of 0.35 and higher are discriminating (very)
good, values from 0.25 to 0.35 are satisfying/good,
values from 0.15 to 0.25 are mediocre/satisfying,
and items with values less than 0.15 are bad/medi-
ocre for discriminating between high scorers and
low scorers.20-23
Setting
The study was performed in the 40-bed ICU of
the 1060-bed Ghent University Hospital, a tertiary
care referral center.
Procedure
The questionnaire’s reliability was assessed by
means of the test-retest method. For test purposes,
the questionnaire was distributed (test) in April 2004
within a time lapse of 2 weeks (T0 to T+2). It was
redistributed for retest purposes within a comparable
period (T+4 to T+6). At T+8 weeks, all questionnaires
were collected. The study was approved by the insti-
tutional review board at Ghent University.
Statistical Analysis
Statistical analyses were performed by using
SPSS version 12.0 (SPSS Inc, Chicago, Illinois).
The items with the most severely skewed distribu-
tion (>97%) were discarded because they are not
likely to be useful for a study on determinants. For
the remaining items, factor analyses with varimax
orthogonal rotation were conducted (data not
shown). As the expert panel found 3 attitude items
and 3 social influence items of rather poor quality,
those items were deleted during the questionnaire’s
development and validation process. The internal
reliability of each factor was tested by using Cron-
bach α. The test-retest reliability of the scales was
assessed with the intraclass correlation coefficient.
Systematic differences were investigated with a
paired-samples t test. To investigate the predictive
validity, Pearson correlations were calculated
between the psychosocial constructs and the self-
reported compliance. Finally, a multiple linear
regression was performed with the self-reported
compliance as the dependent variable and the
behavioral constructs as the independent variables.
All 10 variables were included by using the step-
wise selection method.
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 Results
Response Rates and Population Surveyed
Response rate for the test was 73% (108/148).
Response rate of the retest was 53% (57/108).
Fifty-seven nurses (39% or 57/148) returned both
questionnaires.
The study population was 72% female (n = 78)
and 27% male (n = 29). Data were not available for
1 participant. The number of years of
This questionnaire working experience varied from “less
than 1 year” (12%) to “between 2
identified the and 5 years” (22%), “between 5 and
10 years” (19%), “between 10 and
impact of behav- 15 years” (23%), and “more than 15
ioral determinants years” (23%).
on hand hygiene Item Clustering
compliance. Factor analyses on all attitude and
social influence items led to 3
(AttTime, AttMoral, and AttUse) and 4 (SocNorm, Soc-
Supp, SocPress, and SocRole) interpretable subscales,
respectively (Table 1). For the determinant self-effi-
cacy, no interpretable subscales could be found,
leading to only 1 scale (EffTOT).
Questionnaire Reliability
The paired-samples t test proved the question-
naire to be stable. No systematic differences (data
not shown) were found except for Attmoral (mean
score before, 2.23 [SD, 0.81]; mean score after, 1.99
[SD, 0.69], P = .02, n = 54). Knowledge scores differed
borderline significantly from before to after the test
(mean score before 6.43/12 [SD, 1.65], mean score
after 7.02/12 [SD, 2.19], P = .05, n = 56).
Finally, an intraclass correlation test indicated
acceptable correlations for almost all determinants
(≥0.60), except for AttUse (0.30), Soc-
Behavioral Norm (0.48), and KnowTOT (0.53).
beliefs are Identification and Evaluation of
of great Determinants
Self-reported Compliance. Overall
importance in compliance (12 questions) was scored
at 92%. Because of extremely high
hand hygiene scores (>97.8%), 4 items (ie, “blood
compliance. contact,” “mucosal contact,” “macro-
scopically visible contamination/
pollution,” and “direct contact with body fluids”)
were removed from the questionnaire; the final com-
pliance subscale thus consisted of 8 questions.
Data from an observational study24 in the same
ICU enabled us to recalculate the self-reported com-
pliance rates, taking into account the occurrence rate
of each item. Thus, corresponding weights were given
234 AJCC AMERICAN JOURNAL OF CRITICAL CARE, May 2010, Volume 19, No. 3
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to the 8 remaining items. The recalculated overall
self-reported compliance rate was 82.0% (SD, 15.09%;
n = 105). Rates ranged from 79.2% (SD, 21.4%) for
“contaminated surface contact” to 98.8% (SD, 6.8%)
for “blood contact” and 98.8% (SD, 6.6%) for
“macroscopic dirt contact.”
Behavioral Determinants of Attitude, Social Influence,
and Self-efficacy. On a scale ranging from 1 to 5, the
overall attitude toward hand hygiene scored 3.89.
The overall social influence as experienced by the
respondents scored 3.27. The global self-efficacy
scored 3.55. We also calculated the scores for the
different subscales (as shown and commented on in
Table 1) and looked more closely at a number of
scores on the item level. For example, work pressure
did not prove to influence hand hygiene behavior.
Also, nurses were convinced of the necessity and
effectiveness of proper hand hygiene, but they
clearly underestimated the consequences of poor
compliance and tended to minimize the problem.
Knowledge of Hand Hygiene and Integrity of Knowl-
edge Items. On average, the respondents scored 6.5/12
(SD, 1.76, n = 107) or 54% on the 12-item knowledge
test. Integrity scores (pi values) varied from 0.12 to
0.87 (12% to 87% correct answers). Two questions
were found more difficult than expected: one item
regarding the effectiveness of alcohol-based hand dis-
infection (pi = 0.12, “Alcohol-based hand disinfection
solution has good or excellent antimicrobial effect on
the following organisms, except for… [answering pos-
sibilities]”) and a second item regarding contamina-
tion rates for Methicillin-resistant Staphylococcus aureus
(MRSA, pi = 0.26, “Which percentage of the popula-
tion is represented by MRSA-contaminated? [answer-
ing possibilities]”). One question was found easier
than expected (pi = 0.87, “Most MRSA cases can be
treated successfully with one of the following antibi-
otics: … [answering possibilities]”). Values of d were
bad/mediocre (d = 0.09) for 2 items and mediocre/
satisfying for another 2 items (d = 0.16). All other
items had satisfying to very good d values.
Predictors of Noncompliance
Univariate analysis of the relationship between
the psychosocial constructs and the self-reported
compliance yielded 3 variables that were signifi-
cantly correlated (Table 2). These variables were
included in a multiple linear regression analysis
(Table 3), which identified 2 major determinants as
possible predictors of noncompliant hand hygiene
behavior: self-efficacy (β = .379; P = .001) and AttTime
(β = -.147; P < .001). Hence, ICU nurses reporting
poor self-efficacy or attitude toward time-related
barriers appear to be less compliant.
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 Table 1
Description of dependent and independent variables of hand hygiene compliance

Variable Test score, Cronbach Intraclass

No. of mean (SD) α (test)a correlation
Abbreviation Full name Explanation items (n = 108) (n = 108) (n = 57) Item example

Compliance
ComTOT Total compliance The self-reported total 8 82.0% — 0.78 “How often do you wash or
compliance (mean) (15.1%) disinfect hands in the fol-
lowing situations: skin
contact”
Attitude
AttTime Time-related attitude Attitude toward hand 5 2.14 0.74 0.86 “Washing hands whenever
items hygiene: taking the (0.8) recommended would
“time” aspect into mean precious loss of time
account to me”
AttMoral Morality-related Attitude toward hand 3 2.09 0.52 0.68 “Washing hands saves lives”
attitude items hygiene: taking the (0.8) “I feel bad when not
“moral” aspect into being able to wash
account hands sufficiently”
AttUse Usefulness-related Attitude toward hand 1 1.33 — 0.30 “I am not completely con-
attitude items hygiene: taking the (0.6) vinced of the usefulness
“usefulness” aspect and importance of hand
into account hygiene”
Social influence
SocNorm Normative behavior Social influence on the 1 4.16 — 0.48 “Most of my colleagues think
social influence items work floor: ruling norm (0.8) that hand hygiene prescrip-
tions should be adhered to
as well as possible”
SocSupp Support-related social Social influence on the 1 3.80 — 0.63 “Good hand hygiene prac-
influence items work floor: positive (1.0) tice is appreciated by my
feedback on good professional environment”
behavior

SocPress Pressure-related social Social influence on the 1 2.34 — 0.73 “I receive remarks from
influence items work floor: negative (1.1) colleagues or superiors if
feedback on poor noncompliant”
behavior
SocRole Role model–related Social influence on the 3.71 0.66 0.64 “Most of my colleagues are
4
social influence items work floor: presence (0.62) +50% compliant with
of role models hand hygiene”
Self-efficacy
EffTOT Total self-efficacy Self-efficacy: perception 10 3.55 0.66 0.65 “I would wash hands more
of being able to (1.01) often when more sinks and
behave as desired dispensers were available”
Knowledge
KnowTOT Total knowledge Total knowledge 12 6.5 — 0.53 “Hand disinfection by
(mean score for the (1.7) means of an alcohol-based
12 knowledge items) hand rub is appropriate in
the following situations
except for…”
a Dashes indicate data not reported.

Discussion It is well known that when self-reporting

Validation of the Questionnaire
This article describes the development of a self-
administered questionnaire on hand hygiene for
ICU nurses. The questionnaire proved to be of use
for its specific purpose but has some limitations.
behavior is used, respondents tend to overscore
socially desirable behavior at up to 3 times the
observed compliance rates.25,26 Respondents also
seem to have unrealistic estimations of their own
behavior.5,27,28 Compared with the direct observation

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Table 2
Univariate relationships between potential behavioral predictors
and self-reported hand hygiene compliance (Pearson correlation)

Predictora AttTime AttMoral AttUse SocNorm SocSupp SocPress SocRole EffTOT KnowTOT

ComTOT -0.410b -0.259c 0.075 0.181 0.065 0.131 -0.010 0.507b 0.054

AttTime 1 0.133 0.111 -0.136 -0.063 -0.003 -0.040 -0.632c -0.132

AttMoral 1 0.111 -0.244d -0.179 -0.184 -0.143 -0.236d -0.062

AttUse 1 -0.254d -0.013 0.054 -0.137 -0.159 -0.310b

SocNorm 1 0.293c 0.161 0.669b 0.336b 0.065

SocSupp 1 0.124 0.325b 0.151 0.145

SocPress 1 0.201d 0.123 0.077

SocRole 1 0.274c 0.116

EffTOT 1 0.144

KnowTOT 1
a See Table 1 for an explanation of abbreviations.
b Correlation significant up to .001 level.
c Correlation significant up to .01 level.
d Correlation significant up to .05 level.

Table 3
Linear regression analysis demonstrating adjusted
relationships with total hand hygiene compliance

Nonstandardized Standardized
coefficients coefficients
Independent variable B Standard error Beta t P P after exclusion EffTOT

Attitude toward hand hygiene: taking the -.111 .082 -.147 -1.352 .18 <.001
“time” aspect into account (AttTime)
Attitude toward hand hygiene: taking the -.120 .069 -.151 -1.737 .09 .02
“moral” aspect into account (AttMoral)
Self-efficacy: perception of being able to .412 .121 .379 3.414 .001
behave as desired (EffTOT)

method (the “gold standard”) or indirect measure-
ment of hand hygiene compliance, self-reported
compliance has appeared to have poor validity in
several studies.29 Unfortunately, no standardized
method for measuring compliance is available.29
The compliance was to be scored from 0% to
100% for 12 specific situations. One may question
if these situations represent all possible situations
in which hand hygiene is indicated. Hand hygiene
prescriptions show great variations between differ-
ent countries and therefore also between hospitals.30
Recalculation of the scores with adjustment for occur-
rence rate certainly contributed to diminishing the
response bias to which our results were prone.
It can be assumed that the time interval between
test and retest has led to communication and even
discussion between the respondents on subjects
related to hand hygiene. A small improvement in
hand hygiene knowledge can therefore be attributed
to the time frame of our study. In any event, general
knowledge about hand hygiene practice appears to
be rather low. An identical observation has been
made previously in more specific areas of infection
prevention, such as infections related to central venous
catheters and ventilator-associated pneumonia.31-35
Also, one’s attitude toward the usefulness of hand
hygiene or even the ruling social norm (what others
think should be done) may not be insensitive to the
effects of the interval period, which would explain
the rather poor intraclass correlation coefficients.
The initial questionnaire was found too extensive
and therefore somewhat boring to fill out. Our inves-
tigation allowed us to significantly reduce the number
of items as well as the total length of the questionnaire.

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Analysis of Behavioral Determinants
We found that time-related attitude items and
one’s self-efficacy were strong predictors of hand
hygiene behavior. Neither social influence nor knowl-
edge of hand hygiene guidelines seem to be of any
predictive value.
Attitude. Our respondents’ overall attitude toward
hand hygiene was rather positive. The ICU is known
to be stressful and to have more opportunities for
hand hygiene than other settings. However, increased
work pressure in the ICU did not seem to have a
direct influence on hand hygiene behavior. This
finding contradicts several reports that identified a
high pressure work environment as having a highly
negative influence on hand hygiene.1,8,36-39(p165) Hand
hygiene compliance also seemed to be insensitive
to the moment of care (not associated with a certain
part of the day).
Use of irritating and drying solutions for hand
disinfection was identified as a barrier to proper
hand hygiene. Thus, as confirmed by many other
studies37,40-43 providing sufficient and easy-to-access
skin-friendly products might result in higher com-
pliance with recommendations for hand hygiene.
Although the respondents’ attitudes proved to
be at an acceptable level, further and ongoing
improvement can be worthwhile. Improving one’s
attitude on a long-term basis could be effective
through intensive training and subsequent increase
of one’s knowledge.44,45 According to Larson et al,46
focusing on knowledge in order to improve one’s
attitude should not be effective. Recently a study11
showed that feelings of unpleasantness, discomfort,
and/or disgust lead to emotional sensations that
invoke self-protection and therefore can help in
improving one’s attitude toward good hand hygiene
practice.
Social Influence. The answers indicate an overall
neutral to positive ruling social norm. Social pres-
sure was low: the nurses reported that noncompli-
ance does not easily lead to negative feedback or a
remark from a colleague or from a staff member.
Furthermore, in our study, social influence had no
predictive value. According to Whitby et al,11 a focus
on role modeling, peer pressure, education of
health care workers, and ongoing “cues to action,”
such as posters or easy access to hand rubs can lead
to persistent behavioral change.
Sax et al47 identified highly ranked normative
beliefs as well as perceived social pressure as predic-
tors of compliance with guidelines for hand hygiene.
In the same study, high self-reported rates of adher-
ence to hand hygiene were independently associated
with female sex, receipt of training, peer pressure,
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and perceived good adherence to guidelines for
hand hygiene among colleagues.
Self-efficacy. Global hand hygiene self-efficacy
was scored positively. As reported in other studies,15,16
self-efficacy can be improved by observational learn-
ing (ie, social learning, modeling) and practice.
According to Pittet and O’Boyle, positive feed-
back and subsequent remuneration play a crucial
role in achieving higher self-efficacy.9,39,48,49 Although
a recent study50 showed no significant improvement
in hand hygiene through feedback of process meas-
ures, programs consisting of a combination of edu-
cation and frequent performance feedback did lead
to sustained improvement in hand hygiene compli-
ance51 or improved behavior among health care
workers.52 According to Sax et al,47
adherence is also driven by the per- It is worthwhile
ception of high self-efficacy, rather
than reasoning about the impact of to look at the
hand hygiene on patient safety.
Determinant Mixture? We believe
rationale behind
that behavioral beliefs are of great unacceptably low
importance in hand hygiene compli-
ance. Most successful interventions hand hygiene
appear to be ones that include dif- compliance.
ferent paths in achieving a behav-
ioral change. A combination of educational
programs, the formation of a multidisciplinary
quality improvement team, compliance monitoring,
and feedback has already proven effective.52 As con-
firmed in the same study, evidence-based behavioral
interventions are of growing importance.
Instead of measuring compliance, it appears
worthwhile to have a closer look at the rationale
behind unacceptable low compliance with recom-
mendations for hand hygiene. Motivations and bar-
riers to compliance are to be studied on a higher level.
Our results plead for a “change of focus”: future
surveillance of hand hygiene (including monitoring
and observation, the gold standard) and evaluation
of campaigns should include systematic follow-up
of the ruling social norm, attitudes, and self-efficacy.
Possible next steps include experimental research
in which the effects of feedback and reward on the
nurses’ self-efficacy can be studied. Also, the spe-
cific role and contribution of one’s attitude require
further study through qualitative research such as
focus groups.
Conclusions
We designed a valid questionnaire to identify
the impact of behavioral determinants on compli-
ance with recommendations for hand hygiene. This
questionnaire can be used for further exploration.
237
 Our preliminary results show that a low self-efficacy
and a negative attitude toward time-related barriers
are predictors of poor compliance with recommen-
dations for hand hygiene.
ACKNOWLEDGMENTS
This paper was presented at the 45th Interscience Con-
ference on Antimicrobial Agents and Chemotherapy,
Washington, DC, United States, December 16-19, 2005.
FINANCIAL DISCLOSURES
None reported.
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SEE ALSO
For more about infection control and hand hygiene,
visit the Critical Care Nurse Web site, www.ccnonline
.org, and read the article by Montefour et al, “Acineto-
bacter baumannii: An Emerging Multidrug-Resistant
Pathogen in Critical Care” (February 2008).
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wash their hands: a standardized measurement approach.
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239
CE Test Test ID A1019033: Behavioral Determinants of Hand Hygiene Compliance in Intensive Care Units. Learning objectives: 1. Recognize the
impact of behavioral determinants on compliance with hand hygiene recommendations. 2. Describe determinants of noncompliance with hand hygiene prescrip-
tions among nurses in a general intensive care unit. 3. Understand how a low self-efficacy and a negative attitude toward time-related barriers are predictors of poor
compliance with hand hygiene recommendations.

1. The questionnaire was based on which of the following models? 7. Which of the following was identif ied as one of the strongest
a. Quality management model predictors of hand-hygiene behavior?
b. Stages of change model a. Self-efficacy
c. Consumer information processing model b. Social influence
d. Behavioral theory model c. Moral perceptions
d. Knowledge of hand hygiene guidelines
2. Which of the following is the most effective measure to
prevent cross-contamination? 8. What did researchers f ind related to attitude and hand
a. Transmission-based precautions hygiene?
b. Hand hygiene a. Increased work pressure had a highly negative influence on hand
c. Personal protective equipment hygiene.
d. Appropriate disinfection of reusable equipment b. Hand hygiene compliance was associated with a certain part of the
day.
3. Which of the following is the reported compliance with c. No barriers to proper hand hygiene were identified.
appropriate hand hygiene practices? d. Respondents’ overall attitude toward hand hygiene was rather
a. 10% to 20% c. 50% to 60% positive.
b. 30% to 40% d. 70% to 80%
9. Which of the following was a study f inding about social
4. Which of the following refers to the belief in one’s ability to inf luence and hand hygiene behavior?
behave as desired and to overcome certain barriers? a. Social pressure was high among respondents.
a. Self-determination b. Social influence was a strong predictor of compliance.
b. Self-efficacy c. Answers indicated an overall neutral to positive ruling social norm.
c. Self-concept d. Noncompliance easily led to negative feedback.
d. Self-actualization
10. “Washing hands saves lives” is an item example of which
5. The items on the knowledge scale were selected from a validated variable?
questionnaire on hand hygiene from which of the following a. Morality-related attitude
organizations? b. Total compliance
a. Centers for Disease Control and Prevention c. Time-related attitude
b. World Health Organization d. Usefulness-related attitude
c. The Joint Commission
d. Institute for Healthcare Improvement 11. Which of the following social inf luence variables is explained
as the ruling norm?
6. What was the recalculated overall self-reported compliance rate? a. Support-related
a. 79.2% c. 92.7% b. Pressure-related
b. 82.0% d. 98.8% c. Normative behavior
d. Role model-related

Test ID: A1019033 Contact hours: 1.0 Form expires: May 1, 2012. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.
1. K a 2. K a 3. K a 4. K a 5. K a 6. K a 7. K a 8. K a 9. K a 10. K a 11. K a
Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb
Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc
Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd
Fee: AACN members, $0; nonmembers, $10 Passing score: 8 Correct (73%) Synergy CERP: Category A Test writer: Denise Hayes, RN, MSN, CRNP
Program evaluation Name Member #
Yes No
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Content was relevant to my Country Phone E-mail address
For faster processing, take nursing practice K K
this CE test online at My expectations were met K K RN License #1 State
www.ajcconline.org (“CE This method of CE is effective RN License #2 State
Articles in This Issue”) or for this content K K
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Behavioral Determinants of Hand Hygiene Compliance in Intensive Care Units
David De Wandel, Lea Maes, Sonia Labeau, Carine Vereecken and Stijn Blot
Am J Crit Care 2010;19 230-239 10.4037/ajcc2010892
©2010 American Association of Critical-Care Nurses
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