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Hand hygiene compliance among nursing technicians at a university hospital


Adriana Cristina de OliveiraI; Adriana Oliveira de PaulaII; Camila Sarmento GamaIII; José Ricardo OliveiraIV; Corinne Davis RodriguesV

INurse. Post-doctorate by the New York University. Associate Professor of the Nursing School of the Federal University of Minas Gerais. Brazil. E-mail:
IINurse. Ph.D. by Federal University of Minas Gerais. Brazil. E-mail:
IIINurse. MSc. Ph.D student by the Nursing School of the Federal University of Minas Gerais. Brazil. E-mail:
IVDoctor. Doctorate from the Medicine School of the Federal University of Minas Gerais. Brasil. E-mail:
VPh.D. in Sociology by the University of Texas at Austin. Assistant Professor of the Federal University of Minas Gerais. Brazil. E-mail:





Objective: to measure hand hygiene compliance among nursing technicians and identify determinants of compliance. Method: crosssectional study of thirteen nursing technician at a university hospital in Minas Gerais in May 2012. Data was collected by observation and semi-structured interviews of workers. The project was approved by the Research Ethics Committee (ETIC 0285.0.203.000-10). Results: hand hygiene compliance rate was 35.2%, and facilitating factors mentioned by healthcare workers were: awareness of cross infection, individual protection and availability of material. Adverse factors were lack of training, lack of equipment, and emergency situations. Conclusion: hand hygiene compliance rate among nursing technicians was low. However, the study participants showed they were aware of its importance in infection control and of the team's co-responsibility for transmission of microorganisms.

Keywords: Hand disinfection; cross infection; health personnel; nursing, team.




Handwashing is the act of cleaning the hands using soap and water1, aiming to reduce the microbial load of the hands of professionals, and the transmission of microorganisms among patients, patients and furniture, professional, equipment and furniture. The main sources of pathogens in the hospital environment are colonized and/or infected patients, healthcare workers and the equipment and furniture near the patient2,3.

Thus, always before or after touching the patient, before performing clean/aseptic procedures, after contact with tangible fluids and close surface to the patient, the healthcare workers should perform hand hygiene (HH), cleaning known as HH4 opportunity.

However, the literature reported that despite being aware of the need and importance of HH, the healthcare workers perform it less often and for a shorter period than the recommended5.

From reports of microorganisms transmissions by the hands of professionals and low rates of adherence to HH, there is a need to monitor these practices carried out by professionals. It is necessary to identify the reasons that lead them not to perform HH according to the recommended to develop strategies that increase the adherence rates to this procedure, primarily through changing behavioral and cultural paradigms.

Among the professionals who maintain more contact with patients, there are the nursing technicians who provide ongoing assistance. Often, these workers are associated with the occurrence of cross-transmission of microorganisms through this direct contact, making the fundamental HH practice to ensure the patient safety6.

Given the above, this study aimed to monitor the adherence of nursing technicians in a university hospital to practice hand hygiene and to identify the determining factors for its practice.



Healthcare-associated infections (HAI) are those acquired by the patient during care received in health establishments. They constitute a serious problem and are a common cause of increased morbidity and mortality worldwide7-9.

The HAI affects about 7 to 10% of hospitalized patients and requires more time to recover, reflecting in prolonged hospital stay and, consequently, increasing hospital costs, and affecting the life of the individual in its social, emotional and family context1.

Thus, the HAI is a global health problem, proposed as the theme of the political agenda of the World Health Organization (WHO) expressed by the World Alliance for Patient Safety in two campaigns launched: First Global Challenge for Patient Safety which addressed the HAI and HH; and Second Global Challenge for Patient Safety which addressed safe surgery, demonstrating the need to work globally on prevention10.

Preventing is essential to know the causes that trigger the HAI. One of the most common HAI is the transmission of pathogens by the hands of healthcare workers, who are often subject to contamination by microorganisms during direct contact with body secretions, wounds and even during procedures involving the integre skin, such as measuring the vital data11.

Thus, the practice of hands hygiene constitutes one of the first recommendations, proven effective, simple and low-cost to minimize/reduce and control HAI from cross-transmission of microorganisms and reducing morbidity and mortality in health services, impacting the quality of care and consequently the greater patient security12,13.

However, despite the proven evidence of the importance in reducing HAI, several studies pointed to the low adherence of healthcare workers of HH, estimated to occur in about 15-50% of the recommended conditions, and this neglected practice occurs even in favorable conditions for its implementation6,14.

Healthcare workers are responsible for infection control and patient care free of damage to ensure their safety15. To this end, the practice of HH should be encouraged and inserted in the educational activities of the working process in institutions of health, as well as monitoring and tracking the adherence programs.

In this sense, the WHO proposes longitudinal studies to monitor the adherence of healthcare workers in HH, in a frequent and continuous way to establish comparative parameters, seasonal influences, the insertion of new professionals, the rates of HAI in different sites of infection and different inpatient units over time1.

One of the WHO proposals is the multimodal approach to encourage HH, with actions to raise adherence rates, guided in different realities and contexts1. Such actions consider both the quantitative aspect, about the total opportunities, but also the qualitative aspect, regarding the correct technique of performing it.



It was conducted a cross-sectional study of quantitative approach with nursing technicians of both genders, working in the daytime, acting in a ward with 26 beds of a public university hospital in Belo Horizonte, previously invited and informed about the study objectives, and they agreed to participate by reading and signing the Consent and Informed Form applied by one of the researchers, in May 2012. Those who were on vacation, time off or sick during the period of data collection were excluded.

A direct observation and interview for sociodemographic data collection and identification of the determining factors for joining the HH were performed.

The field observation was performed to identify the adherence rate with hand hygiene. For this step, a form proposed by the WHO was used 16. Two different researchers of those applying the Consent and Informed Form were previously trained for the standardization of this phase of the collection to minimize possible biases of the observer. The HH opportunities were defined according to WHO16: 1st - before contact with the patient, 2nd - before the aseptic procedure, 3rd - after exposure to body fluid, 4th - after contact with the patient, and 5th - after contact with the environment.

The nursing technicians were selected for being the multidisciplinary team and the individual in more direct contact during the care process, performing procedures and proximity to the patient. Of 20 professionals, 13 were observed for 20 minutes, as recommended by the WHO16, during medical practice, in moments of care activities/procedures (from 08:00 to 10:00 for the morning period and 14:00 to 16:00 for the afternoon period).

It should be noted that for this phase of observation, the observer's researchers were introduced in the field as undergraduates who were developing activities related to their course to minimize/avoid behaviors induced by the observer presence, not to arouse possible suspicions about their real presence in the sector.

Data from direct observation were computed and analyzed with the help of statistical software Statistical Package for Social Sciences (SPSS) version 19.0 to identify the adherence rate of professionals and factors related to this adherence. For the processing of data, descriptive analysis was performed, with the absolute and percentage values.

After the primary data analysis, the three professionals who had the highest and the three who had the lowest adherence rates were invited to an interview, and a structured questionnaire was applied to obtain information on the socio-demographic profile and a semi-structured questionnaire with script focused on intervening factors to join the HH. This script was adapted from a study conducted in 200917.

During the interview, the importance of the participant's response was clarified, not being pre-defined right/wrong answers, but rather the opinion of the professional regarding the questioned item. Overall, six interviews were conducted, recorded and transcribed by one of the researchers.

The identification of respondents was targeted in the order that followed the interviews, which occurred upon the availability of the worker. NT 1 was the first to be interviewed; the NT 2 was the second and so on.

The project was approved by the Ethics Committee of the Federal University of Minas Gerais Opinion Nº ETIC 0285.0.203.000-10 respecting the ethical principles of research involving human beings and the Education, Research and Extension Department (DEPE) of the institution study (case Nº 128/10) Minas Gerais.



Adherence rate to hand hygiene

There were 13 nursing technicians followed up, 12 of them (92.3%) were female. During the routine of these professionals, 91 opportunities for hygiene of hands were observed, identifying an adherence rate of 32 (35.2%). It is noteworthy that the observations were in the morning and afternoon, and in the morning the adherence rate to HH was 20 (62.5%) and in the afternoon there were 12 (37.5%). The highest of them - 20 (62.5%) - occurred after contact with the patient, followed by opportunities before contact with patients - 6 (18.8%), after contact with surfaces - 5 (15.6%) before performing aseptic procedures - 1 (3.1%) and after contact with body fluids - 0 (0%).

For the HH, soap and water were used by 20 (62.5%) professionals, soap, and water followed by alcohol by 10 (31.3%) and alcohol gel by 2 professionals (6.3%). In a similar study conducted in a university hospital in the Midwest with healthcare workers, water and soap were also the most used ways to perform the HH18.

Low HH adherence rates found in this study corroborate those of other similar studies that analyzed the adherence through direct observation, as well as studies that reported a higher percentage of HH in the morning shift when compared to the afternoon shift14,18-20.

For the missed opportunities of HH, 13 (22.0%) of these professional were using gloves in the procedures. The adherence rate to HH was different between the observed nursing technicians, and the adherence rates ranged from 0 to 100%.

Determinants factors for HH practice among nursing technicians

The sociodemographic characterization of the six interviewed professionals was represented by 5 (83.3%) of the participants female; mean age of 40 years old; 3 (50%) with higher education in progress; 3 (50%) have seven to nine years of professional qualification and working in the same period in the institution. Regarding employment status, 5 (83.3%) reported having only one job and on the HH training last year, half of the group reported having participated - 3 (50%).

During the interviews, it was observed that professionals know the times when the HH should be performed. They reported that HH should be done before and after each procedure such as preparation and administration of medications, measurement of vital data, bath in patients, change of bed linen, performing dressings, catheter manipulation or bags. It is summarized as washing hands always. It was also noted that this group recognized as recommended in the literature, the HH procedure is one of the main measures to reduce transmission of microorganisms.

The fact that professionals have demonstrated knowledge of the moments when hand hygiene should be performed and the importance of this activity in infection control, even with low rates of adherence to HH, shows that such knowledge is not always related to the attitude of professional as mentioned in other studies18,21.

As the mainly facilitating factors to do the HH practice, there was awareness of cross-transmission, availability of good quality material, conducting research and campaigns on HH, as well as training and continuing education to all professionals. The importance of teamwork and the involvement of all professional categories in training, aiming at adherence to HH practices were also emphasized.

According to a study that developed an educational program to raise the acceptance of healthcare workers to HH after the first and second year, the average rate of nosocomial infections decreased from 15.1 per thousand patient daily for 10.4 and 11.9 per thousand patients per day, demonstrating the impact of continuing education on increasing the adherence of the HH and the safety of the patient22.

It is noteworthy that the low adherence rate to HH obtained in this study may indicate that the factors mentioned by the professionals as facilitators are less than expected in the assessed institution.

The lack of training of professionals, aiming to sensitize and guide them to the correct performance of HH procedure, the unavailability of equipment and emergency care were the limiting factors pointed out by them for the adoption rates in the analyzed extremes (higher and lower rates identified).

The main complicating factor for adherence to HH reported by all the professionals interviewed was the work overload in the sector and the routine of attending several patients. The pressure at work to meet the demands of patients and families, as quoted:

[...] Here the patients want everything for yesterday. So, if you are making a bandage and the other wants you to give the medicine for pain, then it is up to the professional say, 'wait a minute', you go and wash your hand [...] (1 NT aiming not be 'hit' by contingency work routine).

It was observed the report of a professional of university education in the field of nursing increasing the problem for cross-transmission by the medical professional and others, the lack of involvement of those with good practice, to have greater contact with other hospital departments and several patients and use of personal materials without protection.

The training was discussed at various times, and the time that the training take place was also discussed:

[...] If there is a course in the morning, afternoon and night, who is working in the morning, can do it in the afternoon, who is working in the afternoon, can do it in the morning [...] then is the time that we can do it and because during the work schedule, it is very busy [...] (comment from a low adherence rate of Technicians (NT 2).

Also, regarding the need for training and campaigns, the literature cites the importance of involving the patient and his caregiver in this context 23. However, some difficulty inserting them in the process were evident in this study:

[...] There are many patients who are illiterate, there are many caregivers who are illiterate [...] (NT 3).

Although the family members do not have the theoretical notion of cross-transmission of microorganisms, contact precautions, they can be taught on not touching the patients without washing their hands before and after contact, making them active in the control of nosocomial infections23-26.

Thus, there are many limitations to the implementation of what is disclosed in manuals guidelines, pamphlets, banners, plots, being essential to discuss, reflect and develop solutions capable of implementation1.

Besides the importance of continuing education, some professionals mentioned that feedback on hospital infection rates in the sector and comparative studies of other sectors of the hospital could stimulate the adherence.

[...]Yes, I think that you, look, in that period when the washing was smaller [...] finally, you know demonstrating the sector where such wash and the rate fell, [...] and also in the sector they do not wash, for professionals who do not wash [...] (NT 1).

This result corroborates the scientific literature highlighting that when the knowledge of the rates of adherence to biosecurity and infection prevention measures in the sector can serve as an incentive for professionals to improve their performance. This demonstrates the importance of feedback, including as a component of the WHO multimodal strategy for the increase in adherence rates to HH17,24.

The reasons that professionals do not perform the HH were similar to those found in other studies, concerning access to adequate supplies (sinks, soap, and alcohol) and, especially, work overload25. Furthermore, professionals reported also on the dry skin and the need to use moisturizing creams, practice encouraged by WHO, since they are for personal use to prevent cross-transmission of microorganisms among professionals1,17,26.

Health institutions do not always provide adequate materials and in sufficient quantity to perform the services such as sinks for handwashing, dispensers with alcohol gel for HH, liquid soap, and paper towels 27,28. The availability and access to supplies for the HH and the use of well-tolerated products by the skin of professional are factors associated with greater adherence to HH17,29.

However, some fundamental issues have not been addressed by the professionals participating in this study as academic background, knowledge, personality, culture and religion. It is noteworthing that some religions forbid the use of alcohol, making a fact concern in many parts of the world, but of little occurrence in Brazil, since most religions prevailing in the country does not impose this restriction1.

In a similar study, participants claimed lack of social control concerning adherence to the guidelines of HH, the presence of positive and negative model that encourage and discourage the practice of HH, respectively 1, themes not so addressed in this work.

Therefore, the interviewers recognized the collective responsibility of the multidisciplinary team to perform HH:

[...] It protects both the patient and the professional (NT 3).

Some professionals demonstrate clearly that in addition to protecting workers and patients, HH also contributes to the protection of family on both sides, which can be contaminated through cross-transmission, possible by the hand washing oblivion26.

However, they also mentioned dry skin as a disadvantage, highlighting the possibility of improving these side effects to frequent hand washing with the use of moisturizing creams.

It is noteworthy that these lotions should contain glycerin or other astringents in its formulation able to keep their skin hydrated and should not be shared, but for the individual to prevent cross-transmission of microorganisms19.

Thus, it was observed that in some instances the professional assumed to have not performed HH as needed:

[...] It is wrong, we use wedding rings, we use rings [...] we end up forgetting ... and we know we cannot [...]. (NT 2).

While other professional considered the adherence rates in the unit as appropriate:

[...] A colleague who was transferred from one sector where this practice is not exercised as here, he starts to do it just to be in that environment (NT 4).

One limitation of the study was the direct observation methodology used able to modify the behavior of professionals because they are being watched, called Hawthorne effect. To mitigate this problem, graduate student observers were used rather than a professional from the institution, and the observed staff were unaware the time of data collection.



It was found in this study, a low adherence rate to HH of the university hospital nursing technicians. However, these participants showed to know the importance of HH in infection control and co-responsibility of all staff by cross-transmission of microorganisms.

The factors identified as facilitators to raise the HH were: awareness of cross-transmission, availability of good quality material, conducting research and campaigns on HH, as well as training and continuing education to all professionals. The complicating factors were a lack of training of professionals, equipment deficiency, the emergency care and work overload.

Among the strategies seen by professionals as possible to raise the adherence rate to HH, there is the feedback from the infection rates in the sector, and of the institution and results of monitoring adherence to HH, besides the emphasis on continuing education to professionals. It is noteworthy that the low adherence rate to HH obtained in this study may indicate that the factors mentioned by the professionals as facilitators are less than expected in the assessed institution.

Thus, it is clear that hand hygiene is a complex, multifactorial issue, which must be daily worked with the health team as a whole, highlighting the behavioral and personal issues that are closely related to the subject to observe their improvement and, above all, the maintenance of acceptable levels of safety for the health care provided.



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