Determinants of hand hygiene compliance among nurses in the United Kingdom hospitals

Answer

• • 1. 1. Determinants of Hand Hygiene Compliance among Nurses in the United Kingdom Hospitals

          Contents

          Introduction. 5

          Methodology and Methods. 8

          Critical Framework to Be Used. 8

          Literature Review Strategy. 8

          Types of Evidence to Be Considered. 9

          Inclusion and Exclusion Criteria. 10

          Data Extraction. 11

          Findings. 11

          Discussion Summary of Main Findings. 18

          Synthesis of Main Findings. 18

          Clinical Setting Determinants. 18

          Organisational Determinants. 19

          Communication Determinants. 19

          Individual Factors or Determinants. 20

          Recommendations for Practice. 20

          Limitations of Study and Evidence. 21

           

           

           

           

           

           

           

           

           

           

           

          Abstract

          Health care related infections are increasingly drawing significant attention from governments, patients, regulatory bodies, government, and insurers. Hand hygiene happens to the most effective and simplest mechanism of preventing health care-associated infections. However, despite the simplicity associated with this measure along with the progresses accomplished in infection control, compliance with hand hygiene recommendations still remains low among health care workers in hospitals including nurses. It is within this context that this study focused on addressing the research question concerning the determinant of hand hygiene adherence among nurses within the United Kingdom hospitals. The study was based on the review of the existing studies that focus on determinants of HH compliance among nurses in the UK.  Literature search was conducted on reputable academic databases and websites such as EBSCO, CINAHL, Google Scholar, and ScienceDirect. The finding revealed several determinants of HH compliance that fall under five major categories including individual factors, communication determinants, organisational determinants, and clinical setting determinants. The study concludes that improving HH compliance can be accomplished by embracing a comprehensive approach focusing on interventions such as education and training, provision of equipment and materials, awareness creation, and hospital leadership support among others.

          Key Words: Hand Hygiene Compliance, Hand Hygiene Determinants, Nurses Compliance, hand hygiene practices

           

           

           

           

          Determinants of Hand Hygiene Compliance among Nurses in the United Kingdom Hospitals

          Introduction

          Health care related infections are increasingly drawing significant attention from governments, patients, regulatory bodies, government, and insurers. Reveals (2012) defines health care acquired infections (HCAIs) as infections that first occur 48 hours or even more hours following hospitalisation or within 30 days following the reception of health care. Word Health Organisation (2020) defines HCAIs as an infection happening in a patient in the course of care within a hospital or facility of health care, which was not incubating or present at the admission time. This terminology initially referred to infections associated with admission to an acute-care hospital, but currently encompasses infections developed within different settings where patients acquire health care such as long-term care, ambulatory care, home care, and family medicine clinics among other care delivery settings (Haque et al., 2018; Infectious Disease Prevention and Control (IPAC) 2013; Fox et al. 2015). Proper hand hygiene contributes to the prevention of infection within hospitals, which in turn reduces illnesses complication, length of stay in hospital, care cost, and hospital readmission rate (Kolawole, 2020).

          According to Chavali et al. (2014), health care related infections affect one out of every twenty hospitalized patients. These infections can kill between 20 and 30% of patients (Fresh and Clean 2019). According to Guest et al. (2020), HCAIs continue to cost up to approximately £2.7billion and result in about 28500 patient deaths, 79700 days of absenteeism days among frontline health care practitioners, and 7.1 million engaged or occupied bed days. This situation is not only attributed to the complexity of the problem in relation to associated mortality, cost of treatment, and morbidity, but also linked to the growing acknowledgment that of these infections are preventable. Hand hygiene happens to the most effective and simplest mechanism of preventing health care-associated infections (Mathur 2011; Guest et al., 2020; Hillier 2020; Nazarko 2016; Mokobi 2020; Gould et al. 2017; Stephenson 2019; Shobowale et al., 2016; Erasmus 2012; Strigley et al. 2016; Huis et al. 2013). Hayden (2014) defines hand hygiene as process of cleaning hands without or with the use of another liquid or water or with the employment of soap, with the aim of removing dirt, soil, and microorganisms. In light of the increasing burden of health care related infections, the growing severity of disease and treatment complexity, and overlaid by multi-drug resistant pathogen infections, practitioners in health care are reverting to the fundamentals of infection preventions by embracing simple measures such as hand hygiene (Mathur, 2011).

          According to Mathur (2011), the conceptualisation of the significance of hand hygiene was done in the early years of the 19^th century. The first evidence of the effectiveness of hand decontamination in reducing the puerperal fever incidence and maternal mortality was provided by Labarraque and Porter (1831). In 1840s, studies executed in Vienna, Austria and Boston, USA by Ignaz Semmelweis and Oliver Wendell Holmes respectively established that the transmission of hospital-acquired illnesses occurred through the hands of health care workers (Mathur 2011; Saeidi 2015). In 1847, Semmelweis was given the position of a house officer within one of the two obstetric clinics situated within the University of Vienna Allgemeine Krankenhaus (Saeidi 2015). His breakthrough came after the demise of colleague Jokob Kolletschka, who was accidentally cut by a learner’s scalpel while executing an autopsy (Mathur 2011). His autopsy revealed that a pathological condition, which resembles that of women drying from puerperal fever (Mathur 2011). Semmelweis reached a conclusion that an unknown cadaverous material resulted in puerperal fever. Moreover, he observed that rates of maternal mortality, mostly associated with puerperal fever, were significantly higher within one clinic relative to the other, with maternal mortality rates of 16% against 7% (Saeidi 2015). Semmelweis also noted that medical students and doctors always went directly to delivery room after executing autopsies and an unpleasant odour on their hands even thought they had washed them with water and soap prior to entering the clinic (Saeidi 2015). Therefore, he hypothesized that the transmission of cadaverous particles occurred through the hands of students and doctors from the autopsy room to the theatre of delivery and resulted in puerperal fever. As a result, he implemented a policy of washing hands using chlorinated lime, particularly for individuals leaving the autopsy room. This undertaking resulted in maternal mortality rate dropping ten-folds (Mathur 2011). Thereafter, this fall in maternal mortality rate remained constant (Saeidi 2015).

          Since the breakthrough witnessed by Semmelweis, hand hygiene has increasingly gained significance as an effective measure for preventing HCAIs. For instance, in 2005, the World Health Organisation (WHO) introduced the pioneering Global Patient Safety Challenge known as Clean Care is Safer Care (CCiSC) as a component of its global alliance for patient safety (Mathur 2015). In 2006, WHO published advanced draft measures on Hand Hygiene in Health Care and developed, as well as tested a set of implementation tools (Saedi 2015). In 2009, WHO emphasised the significance of hand hygiene by launching tools and guidelines on hand hygiene (Mathur 2015). However, despite the simplicity associated with this measure along with the progresses accomplished in infection control, compliance with hand hygiene recommendations still remains low among health care workers in hospitals including nurses (Erasmus et al. 2010; Conway & Langley 2013; Sendall et al. 2019; Roy 2017; Sands and Aunger 2020; Engdaw et al. 2019; Levchenko et al. 2011 ). Since nurses possess the most frequent interactions with patients during care delivery, they have more opportunities for practicing hand hygiene (Sendall et al. 2019).  Therefore, there is a significant need for the identification and comprehension of determinants of hand hygiene compliance among nurses. It is within this context that this study will focus on addressing the research question concerning the determinant of hand hygiene adherence among nurses within the United Kingdom hospitals.

          Methodology and Methods

          Critical Framework to Be Used

          The Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) model by Moher et al. (2010) was adopted as the critical framework for conducting the literature review. This model consists of four-phase flow diagram including identification, screening, eligibility, and included (see figure I in the appendix). The PRISMA model contributes significantly to improving the reporting and critical appraisal of meta-analyses and systematic reviews. As such, the author considered it appropriate for this literature review.

          Literature Review Strategy

          The integrative review strategy was adopted as the preferred literature review strategy for this study. According to Walliman (2015) and Tang et al. (2013), the integrative review strategy enables the integration, as well as appraisal of findings from quantitative and qualitative research. In this integrative review, the PRISMA framework, which serves as a screening tool for the selection and evaluation of data, was employed. The process of data analysis was associated with three distinct sub-processes including iterative, deductive, and coding, with the aim of identifying and analysing findings or results of the primary research studies employed as data for the review. Walliman (2015) defines iteration as a reflexive process employed in making meaning from study or research data. In relation to this, the findings associated with primary studies were subjected to analysis cycles and patterns of data were revisited as patterns emerged.  New cycles were undertaken as insight was sparked and novel patterns emerged. Similarly, the deductive analysis process was employed, starting with a wide spectrum of information on the subject of hand hygiene in general followed by narrowing it down to a more precise or specific hypotheses associated with compliance or adherence among nurses after which a logical progress was embraced. When it comes to grouping the information, the author established a coding structure that also permitted the establishment of refined themes. Moreover, every primary study was granted a number, with the aim of providing ease of readability of data associated with integrative review.

          Types of Evidence to Be Considered

          Hennink et al. (2020) assert that not all nursing research evidence is the same, and that appraising the evidence quality is a significant component of research for evidence-based practice. The evidence hierarchy is typically represented as shape of pyramid, with the weaker, smaller, and more copious research studies being situated near the pyramid’s base, and systematic reviews, as well as meta-analyses located at the top level with higher validity, but a more restricted range of topics. The types of evidence include level I, level II. Level III. Level IV, and level V. This study did not put any limitation to the type of evidence to be included in addressing the research question. All types of evidence were taken into consideration to ensure that the weakness of any type of evidence is addresses or compensated by other types of evidence. Such an undertaking enabled the author to address the research question in-depth by establishing all the determinants of hand hygiene adherence among nurses in the UK. Nonetheless, more focus was directed towards systematic reviews without or with an included meta-analysis as this type of evidence offers the best evidence for all types of questions considering that they are founded on the findings of multiple researches or studies as suggested by Walliman (2015).

          Inclusion and Exclusion Criteria

          Establishing exclusion and inclusion criteria is considered a standard practice for designing high-quality study protocols (Patino & Ferreira, 2018). Patino and Ferreira (2018) define inclusion criteria as the primary features associated with the target population or subjects that investigators will employ in answering their research queries. On the other hand, exclusion criteria refer to aspects or characteristics of the potential research subjects or participants, who meet the criteria for inclusion but present with extra features that could negatively impact or interfere with the study’s success or even increase the likelihood of unfavourable outcomes (Hennink et al. 2020). According to Taylor et al. (2015), exclusion and inclusion criteria establish the boundaries for the execution of literature reviews. These criteria are set after the development of the study question usually prior to executing the search.  Nonetheless, scoping searches may be undertaken to establish appropriate criteria (Walliman 2015). Several factors can be employed as exclusion or inclusion criteria including date, exposure of interest, study’s geographical location, participants, language, type of publication, study design, setting, reported outcomes, and peer review.  For this study, the inclusion criteria were primary sources

          from UK and countries similar to the UK such as Canada and Australia, studies focusing on the research question, which in this case was the determinants of hand hygiene compliance among nurses in UK, studies published in English, and studies not older than ten years since their publication time.  The exclusion criteria included studies not published in the UK, Canada, and Australia, studies not published in English, studies older than ten years since their time of publication, and studies no focusing on the research question. Literature search was conducted on reputable academic databases and websites such as EBSCO, CINAHL, Google Scholar, and ScienceDirect. 189 articles were identified out of which 15 studies met the inclusion criteria for the study. 94 were excluded for not being published in UK, Canada, or Australia, 56 were excluded for being older than ten years since their publication time, 21 were excluded for not focusing on the research question, and 3 were excluded for not being published in English.

          Data Extraction

          Data extraction was founded on the research query, on the determinants of hand hygiene adherence among nurses within UK hospitals. To ensure effective extraction of data, a table was development with a column for the researchers, type of study, and findings in relation to the determinants of hand hygiene compliance among nurse. This step was the followed by four stages of data extraction including aggregating, organizing, comparing findings, and organization.

          Findings

          This chapter presents an analysis of the findings of the 15 articles that met the inclusion criteria in relation to the determinants of hand hygiene compliance among nurses within hospitals in UK. Hart (2013) considers hand hygiene a critical intervention that ought to be embraced at all moments and in the appropriate way by all health care professionals who handle patients. The author asserts that ensuring that all health care practitioners accomplish this goal depends on evidence and knowledge being translated into practice in a consistent manner, including through up-to-date education sessions and training, and through establishing competence. The Author proceeds to state that even though the prevention and control of infection teams play a significant role in the attainment of this goal, infection prevention is not their sole responsibility and should be an undertaking of all health care stakeholders.

          White et al. (2015a) conducted a primary study on comprehending the determinants of hospital nurses’ hand hygiene practices after the implementation of a national hand hygiene programme. The study focuses on nurses from 50 Australian hospitals. The outcomes of the regression analysis revealed that subjective norm, perceived behavioural control (PBC), risk susceptibility, group norm, and subjective knowledge were significant predictors of hand hygiene intentions of nurses, with PBC and intention predicting their compliance mannerism. The authors concluded that health education strategies ought to focus on perceptions of risk and control and normative influences in their efforts to promote hand hygiene adherence, as opposed to targeting attitudes that are already favourable among nurses.

          In another study conducted by Atif et al., (2019), the authors employed observations and interviews in gaining insight and finding detailed results on factors that determine the compliance of nurses with hand hygiene in Quebec. Contrary to the study by White et al. (2015a), which only focused on a single quantitative data collection technique, the study by focused on two qualitative data collection methods and targeted 83 nurses (65 interviews plus 18 observations, which is a bigger number than the number of nurses targeted by White et al. (2015a). The findings of the study showed several factors that influence the compliance of nurses within the recommendations of hand hygiene. These factors included clinical setting factors such as absence of sinks, and organisational factors such as demanding workloads and inadequate staffing. Other factors revealed by the study findings as determinants of hand hygiene among nurses were communication factors such as dissemination of information about infection control and prevention, interpersonal professional relationships, and feedback. At the level of individual, risk perceptions and knowledge were established to influence adherence to hand hygiene measures, which were also revealed by the outcomes of the study executed by White et al., (2015a). The authors concluded that comprehending the determinants for the adoption of hand hygiene measures is vital for improving present practices and reducing rates of hospital acquired infections within hospitals. Moreover, the author recommended the measures that should be embraced to encourage compliance with hand hygiene including environmental strategies such as hand hygiene stations and installation of extra sinks, communicational and organisational strategies like training sessions and continuing education, positive feedback, and support from hospital management.

          In a different study, White (2015b) employed a planned behaviour framework theory in exploring hand hygiene beliefs at the five critical moments among nurses in Australian hospitals. The findings of the study revealed the determinants of HH adherence, which were categorised in five themes including important advantages, disadvantages, referents, barriers, and facilitators. Factors categorised as important advantages were protection of self and patients, whereas the aspects of hand damage and time were categorised as disadvantages. Referents were classed into two groups including supportive and unsupportive. Supportive referents were colleagues and patients, whereas unsupportive referents were some doctors. Barriers included being too busy and emergency situations, while facilitators included reminder, training, and accessibility of products and sinks. Furthermore, the findings revealed the existence of some equivocation concerning the relative significance of hand washing after contact with patient environment.

          Kupfer et al. (2019) employed the Interpersonal Behaviour theory as a comprehensive framework for comprehending the determinants of hand hygiene behaviour. Self-reported questionnaire was administered to 75 participants, who reported their hand hygiene (HH) mannerism and responded to questions rating the significance of self-protection, social norms, time pressures, access to equipment, patient protection, disgust, and habit to their HH mannerism. The findings of the regression analysis revealed that time constraints were the strongest predictor followed by challenges finding the equipment. The authors concluded that time constraints are the most significant influence on HH compliance among the determinants studied. Nonetheless, the authors recommended future studies to employ other theoretical frameworks in gaining more inclusive comprehension of the psychology underlying compliance with HH and embracement of HH interventions.

          In a focus ground study executed by Jang et al. (2010) among health care workers within a Teaching Hospital in Toronto in Canada, the subjects reported that the realities associated with their workload such as interruptions and urgent care presented a challenge to hand hygiene. Participant described the guidelines as overly conservatives and expresses that their opinion is sufficient to establish when to execute hand hygiene. Moreover, discussions revealed gaps within knowledge among subjects and most of them expressed concern in more education and information. Besides, participants mentioned self-protection as the key reason for the execution of HH, and most of them agreed to prolonged use of glove, as it granted them a sense of safeguard. Restricted access to HH products was also considered a source of disappointment as was confusion associated with hospital equipment perceived as the potential vehicle for infection transmission. Participants reported that they observed other health care workers compliance and stated that hygiene practices of other health care workers such as physicians influenced their own practices and attitudes.

          Alshehari et al. (2018) focused on the identification of the effective interventions for enhancing compliance with hand hygiene among health care workers within adult intensive care units. The findings showed that a combination of administration supplies, support, training and education, surveillance, reminders, and performance feedback increased the level of compliance from a baseline of 51.5 percent to a record of 80.1 percent. The authors concluded that multi-modal interventions contribute largely to raising adherence to hand hygiene measures to the desired standards.

          Winship and McClunie-Trust (2016) performed an integrative review of factors influencing compliance with hand hygiene among nurses. The outcomes of the appraisal conducted by the authors revealed five primary themes relating to determinants of HH compliance including awareness of being observed, busyness and time constraints, HH as self-protection and risk self-analysis, role modeling and social pressure, and conversion of knowledge into action and transforming intention into behaviour.   

          Gluyas (2015) employed the perspective of human factors in exploring elements that influence hand hygiene compliance among health care workers. The author established that mistakes, lapses, and slips can occur depending on the level of knowledge and skills of practitioners. Moreover, the study findings showed that breach of protocols may occur and these factors may be associated with the intention of providing care in an efficient way. The author concluded that robust leadership and a comprehension of the reasons for non-compliance helps with the development of effective strategies for improving compliance.

          Njenje (2018) evaluated the influence of educational program on the compliance with hand hygiene measures among health care workers within the intensive care unit.  To accomplish this goal, the author employed the Health Belief Model as the study framework. Key aspects of the model relating to determinants of HH were perceived susceptibility, perceived barriers, perceived benefit, and perceived severity. The study results were supported the existing evidence concerning the effectiveness of education in improving HH adherence and that effective HH minimises infections. The author concluded that the study findings may contribute significantly to positive social transformation by promoting increased knowledge about HH, while reducing complications of costs, treatments, mortality, and morbidity.

          Jeanes et al. (2017) executed a study targeted at identifying, removing, and reducing barriers or hindrances to hand hygiene adherence within an emergency department. The outcomes of the study showed that ambiguity concerning when to clean hands, operational, and environmental issues were some of barriers to HH adherence. Moreover, urgency of work within certain department areas leaving limited time of hand hygiene was also established as a hindrance to HH compliance. To some staff, the aspect of physical wellbeing, particularly sore hands was established as a barrier to compliance with HH. The authors also established that the presence of a monitoring tool plays a vital role in addressing barriers to HH adherence except in emergency circumstances that require further work of improvement. In a different study executed by Kingston et al. (2017), the authors established that factors related to physical wellbeing of nurses such as skin sensitivity and skin damage, and individual nurse factors such as poor user tolerance and acceptability determined the ability of nurses to adhere to HH.

          Wyeth (2013) emphasises the significance of providing necessary facility or equipment within the clinical setting and ongoing training, as well as support of staff as essential factors for ensuring adherence to HH and other practices associated with infection prevention and control. In another study, Ryan (2012) investigated the determinants of HH among registered nurses providing care for critically ill infants within the neonatal intensive care unit (NICUs). The findings revealed factors such as attitudes, intentions, subjective norms, age, and perceived behavioural control as determinants of HH adherence. The author recommended that efforts targeted at improving adhering to HH among NICU nurses should be focused older NICU nurses and Theory of Planned Behaviour (TPB) concepts. Aziz (2013) highlights the significance of educational awareness campaigns and availability of alcohol hand-rub and hand-washing materials as determinants compliance with HH requirements.

          In summary the findings of the reviewed literature reveal that there several determinants to compliance with hand hygiene recommendations among nurses within the UK hospitals. These factors include education and training (Aziz 2013; Wyeth 2013; Jeanes et al. 2017; Njenje 2018; Gluyas 2015; Winship and McClunie-Trust 2016; Alshehari et al. 2018; Jang et al. 2010; White 2015b; Atif et al. 2019; White et al. 2015a; Hart 2013), group norm (Hart 2013; White et al. 2015a; Jang et al. 2010; Atif et al. 2019), risk susceptibility (White et al. 2015a; Atif et al. 2019; Winship and McClunie-Trust 2016; Njenje 2018; Kupfer et al. 2019; Jang et al. 2010), subjective norm or social pressure (White et al. 2015a; Kupfer et al. 2019; Winship and McClunie-Trust 2016; Ryan 2012), perceived behavioural control (PBC) (White et al. 2015a; Ryan 2012; Kupfer et al. 2019), availability of equipment (Atif et al. 2019; Wyeth 2013; Aziz 2013); demanding workloads and inadequate staffing  (Atif et al. 2019); awareness creation (Atif et al., 2019; Alshehari et al. 2018; Winship and McClunie-Trust 2016); physical wellbeing (White, 2015b; Jeanes et al. 2017; Kingston et al. 2017), time or urgency (White 2015b; Kupfer et al. 2019; Jang et al. 2010; Winship and McClunie-Trust 2016; Jeanes et al. 2017), support (Atif et al., 2019; White 2015b; Alshehari et al. 2018; Wyeth 2013), accessibility of equipment (White 2015b; Kupfer et al. 2019; Jang et al. 2010; Alshehari et al. 2018, performance feedback (Alshehari et al. 2018), age (Ryan 2012), attitude (Kupfer et al. 2019; Ryan 2012; Kingston et al. 2017), intention (Kupfer et al. 2019; Ryan 2012; Winship and McClunie-Trust 2016; Gluyas 2015), overly conservative guidelines (Jang et al. 2010), surveillance (Alshehari et al. 2018; Jeanes et al. 2017), and perceived benefit (Njenje 2018). The subsequent section will discuss and summarize these factors in five major themes or topics.

           

           

          Discussion Summary of Main Findings

          Synthesis of Main Findings

          This study focused on the investigation of the determinants to compliance with hand hygiene recommendations among nurses within UK hospitals. From the review of the existing evidence the findings of the paper reveal there are several factors that determine nurses’ adherence to hand hygiene practices in UK hospitals. These factors can be categorised into five major groups identified by White et al. (2015a) as discussed in the subheadings below:

          Clinical Setting Determinants

          Availability of equipment and materials such as sinks and alcohol-based hand-rub and referents were considered determinants of HH compliance among nurses. The absence of materials and equipment such as sinks and alcohol hand-rub was established to be a disappointed among nurses (Kupfer et al. 2010; Jang et al. 2019). Apart from equipment and materials, referents such as colleagues, patients, and doctors also played a significant role in determining nurses’ compliance with HH measures. Supporting referents such as patients were served as catalysts to adherence with HH practice among nurses whereas unsupportive referents including some doctors hindered nurses from complying with HH recommendations (Kupfer et al., 2010). It is also significant to note that social pressures and group norms influenced the adherence of nurses to HH practices. For instance, the article by Jang et al. (2019) revealed that the compliance of other health care workers including physicians with HH measured positively influenced nurses’ adherence to these measures.

          Organisational Determinants

          Organisational factors such as education and training, support, and workloads also acted as determinants of HH adherence among nurses. The presence of training and education was considered a positive influence on HH compliance. On the other hand, low education or knowledge level was considered a negative influence on HH adherence as it result in issues such as breach of HH protocols, slips, lapses, and mistakes when it comes to complying with HH practices as founded in the article by Gluyas (2015). Moreover, demanding workloads and inadequate staffing were also established to negatively impact HH compliance. The aspect of urgency or time predicted the ability of nurses to comply with HH measures. For instance, the article by Winship and McClunie-Trust (2016) identified busyness and time constraints as negative predictors of HH compliance among nurses. Surveillance was also identified as a determinant of HH adherence (surveillance (Alshehari et al. 2018; Jeanes et al. 2017). For example, Winship and McClunie-Trust (2016) established awareness of being observed as a positive predictor of HH adherence among nurses, while Alshehari et al. (2018) established that education and training increased conformance to HH requirements.

          Communication Determinants

          Factors such as awareness creation, feedback, and relationships were established to be communication determinants of HH adherence. For instance, the article by Atif et al., (2019) identified the capability of disseminating information about infection prevention and control as a positive influence on HH conformance, whereas Alshehari et al. (2018) established that the provision of performance feedback positively influenced nurses’ compliance with HH requirements. The presence of interpersonal professional associations was established as a positive influence on adherence to HH recommendations (Atif et al. 2019). Moreover, overly conservative guidelines were identified as negative predictors of HH compliance (Jang et al., 2010). Jeanes et al. (2017) identified ambiguity concerning when to clean hands as negative influence of HH adherence.

          Individual Factors or Determinants

          The findings showed that there exist several individual factors that determine nurses’ compliance with HH requirements. These factors include risk perceptions, knowledge, physical wellbeing, intention, attitude, and age. High perception of risk of infection positively impacted compliance with HH practice (White et al., (2015a). Physical wellbeing was also identified as a determinant of adherence to HH. For instance, factors such as sore hands (Jeanes et al. 2017), Hand damage (White et al. 2015b), skin sensitivity and skin damage (Kingston et al. 2017) negatively influence nurses’ adherence to HH practice. Intention to provide efficient care (Ryan 2012; Gluyas 2015) and protect patients (White 2015b; Kupfer et al. 2019), and protect self (White 2015b) positively influence HH compliance. Attitude related factors such as disgust (Kupfer et al. 2019) and poor user tolerance and acceptability (White et al. 2015a) impact HH compliance in a negative manner. When it comes to age, older nurses have a tendency of not conforming to HH requirements (Ryan 2012).

          Recommendations for Practice

          Considering the outcomes of the study, the following measures are recommended for health care organisations or hospitals in UK as measures for enhancing hand hygiene practice among nurses:

          • Hospitals in UK should focus on adopting or implementing environmental strategies such as establishing hand hygiene stations (White et al. 2015a)
          • Involve of all stakeholders including nurses, physicians, and health care cleaners in hand hygiene initiatives (Hart 2013).
          • Focus health education strategies on perception of risk and control, as well as normative influences as suggested by (White et al. 2015a)
          • Provide adequate equipment and materials including sinks and alcohol-based hand-rub (Wyeth 2013)
          • Provide necessary training and education, as well as awareness on hand hygiene and its significance in infection prevention and reduction of care costs (Wyeth 2013; Hart 2013).
          • Establish hand hygiene documents that are simple and clear to understand to avoid issues of ambiguity or documents being too conservative as identified by (Jang et al., 2010) and Jeanes et al. (2017).
          • Supporting HH initiatives and providing positive performance feedback to nurses (White et al. 2015a)
          • Focus hand hygiene interventions largely towards older nurses as they have a tendency of not conforming to HH requirements (Ryan 2012).

          Limitations of Study and Evidence

          This study was based on the review of the existing studies that focus on determinants of HH compliance among nurses in the UK. However, certain limitations were associated with the study that could compromised the outcomes or negatively impact the findings of the study. The first limitation is that considering that the study was a literature review, there are possibilities of the researcher inheriting errors or biases from the authors of the articles or studies that were incorporated in this study. These biases could have negatively impacted the findings. The second limitation is that the issue of researcher bias could have occurred during the selection of the articles to be included in this study, and this could have impacted the findings in a negative manner. The third shortcoming of this study is that certain studies conducted within the contexts of Australia and Canada were included in the paper owing to the limited studied that focus on determinants of HH compliance among nurses within the context of UK. The author opted for this approach as the health care systems of these countries share certain similarities with that of the UK.  As such, some the findings of this study might not accurately capture of the determinants of HH adherence among nurses in UK hospitals. In relation to this, future studies should focus on conducting primary research within UK hospitals, as this can enable them to gather firsthand and precise information concerning HH compliance among UK hospitals’ nurses.