REVIEW

Measuring handwashing performance in health

service audits and research studies
D.J. Gould
a,
*, J. Chudleigh
a
, N.S. Drey
a
, D. Moralejo
b
a
City University, London, UK
b
Memorial University, St Johns N.L., Canada
Available online 11 April 2007
KEYWORDS
Handwashing;
Hospital-acquired
infection; Observation
Summary Handwashing is regarded as the most effective way of control-
ling healthcare-associated infection. A search of the literature identied
42 intervention studies seeking to increase compliance in which the data
were collected by directly observing practice. The methods used to under-
take observation were so poorly described in most studies that it is difcult
to accept the ndings as reliable or as valid indicators of health worker be-
haviour. Most studies were limited in scope, assessing the frequency of hand-
washing in critical care units. The ethical implications of watching health
workers during close patient contact were not considered, especially when
observation was covert or health workers were misinformed about the pur-
pose of the study. Future studies should take place in a range of clinical set-
tings to increase the generalizability of ndings. Observation should be
timed to capture a complete picture of 24 h activity and should include all
health workers in contact with patients because all have the potential to
contribute to cross-infection. Reported details of observation should in-
clude: vantage of data collectors; inter-rater reliability when more than
one individual is involved; and attempts to overcome the impact of observa-
tion on usual health worker behaviour. Ideally an additional data collection
method should be used to corroborate or refute the ndings of observation,
but no well-validated method is presently available.
2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.
Introduction
Hospital-acquired infection (HAI) is a major prob-
lem in modern health care and a source of concern
to health workers and the public.
1
Handwashing is
considered the single most effective and cost-
effective means of reducing HAI.
2
However, health
* Corresponding author. Address: City University, School of
Nursing and Midwifery, 24 Chiswell Street, London EC1 4TY,
UK. Tel.: 44 0207 0405449; fax: 44 0207 0405866.
E-mail address: d.gould@city.ac.uk
0195-6701/$ - see front matter 2007 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2007.02.009
Journal of Hospital Infection (2007) 66, 109e115
www.elsevierhealth.com/journals/jhin
workers wash hands too seldom, not always at the
most appropriate times and technique is subopti-
mal.
3e7
Numerous approaches have been used to
increase hand hygiene compliance. Intervention
studies have been systematically reviewed by
Naikoba and Hayward.
8
Critique was offered about
study design and there was detailed comparison
between the different types of interventions and
their success. In all but two of the 21 studies re-
viewed, direct observation was the main method
of data collection. However, the rigour of observa-
tion as a method of data collection was not dis-
cussed. This omission is surprising as the validity
and reliability of the ndings obtained in behaviou-
ral studies depend on the appropriateness of the
method used to collect data.
9
The extent to which
participants were aware they were being watched
and the impact on their usual behaviour is a key
issue, especially in studies where handwashing is
the activity of interest.
6,9e12
Methods
A literature review was conducted to describe and
evaluate direct observation used as the main
method of obtaining data in studies seeking to
increase hand hygiene compliance. Papers were
identied from the following computerized data-
bases: MEDLINE, CINAHL, EMBASE, and the
Cochrane Library. Additional search strategies in-
cluded: searching the internet with a general
browser; screening the reference lists of papers
already retrieved; and handsearching key journals
(British Medical Journal; Journal of Hospital Infec-
tion; American Journal of Infection Control ). At-
tempts were made to locate material in the grey
literature. Key words used were: handwashing
and hand hygiene. To meet the inclusion criteria
for review, papers had to be empirical studies
undertaken to increase compliance with handwash-
ing for health workers using aqueous solutions
and/or alcohol-based products. Studies designed
to increase compliance by individuals other than
health workers were excluded. Also excluded
were opinion pieces and general reviews. Data
collection had to include direct observation of
handwashing, although it was permissible for addi-
tional methods to be employed (consumption
of soap/alcohol handrubs, monitoring devices
attached to taps).
All abstracts were inspected to ensure that they
met the inclusion criteria. Eligible papers were
downloaded, read and scrutinized by at least two
readers. The data were extracted onto a template
developed especially for the review.
Results
The searches identied 41 300 papers. Forty-two
met the inclusioncriteria. Eighteenof the 21 studies
reviewed by Naikoba and Hayward were eligible.
8
Two were discounted because handwashing compli-
ance had not been assessed by direct observa-
tion.
13,14
A third paper
8
was dismissed because, on
careful reading, it proved not to report an interven-
tion.
15
Twenty-four new intervention studies using
observation as a method of data collection were
identied in addition to a report by Pittet et al.
which had been discussed in an annex attached to
the review by Naikoba and Hayward.
8,16
One paper
appeared to be a follow-up of the original work in
Geneva and was not included.
17
What was observed
All the studies examined frequency of handwashing
and/or use of alcohol products. The hand hygiene
event was clearly dened in half the papers, usually
with reference to the Association for Professionals
in Infection Control and Epidemiology (APIC) or
other published guidelines.
18
In 13 papers hand-
washing was considered to be essential before and
after patient contacts and/or when moving from
one patient to another.
19e31
In nine papers compli-
ance was considered in relation to the number of
opportunities for handwashing.
16,32e39
The others
did not offer clearly dened criteria for when hands
should be washed. Nine studies assessed handwash-
ing technique each using a different method of
evaluation.
33,34,39e45
Who was observed
In seven studies, data were collected for all
personnel visiting a ward or unit.
16,23,35,36,46,47
In others, observation was restricted to
particular occupational groups: doctors
28,29
;
nurses
24,30,34,37,38,41,45,48e50
; occupational thera-
pists
51
; technicians
52
; and preclinical medical
students.
53
The remaining studies appeared to
include professionally qualied staff (doctors,
nurses, therapists) but not ancillary staff. Six stud-
ies involved an entire hospital.
16,19,26,28,40,49
Of
those studies not performed on a hospital-wide
basis, only ve took place outside critical care
units.
23,34,47,50,54
How observation was conducted
Non-participant observation was employed in 41
studies. In six studies, a supporting method of data
110 D.J. Gould et al.
collection was also employed (consumption of
soap/alcohol, monitoring devices attached to
taps).
16,33,41,46,47,49
Rates of HAI were included as
an outcome measure in six studies.
16,39,47,49,55,56
In
one study the method of observation was unclear.
45
In another study, health workers collected data on
each other and it was not clear whether this took
place while they were undertaking their usual clini-
cal duties.
38
One research team employed partici-
pant observation in which the data collector was
a member of the usual nursing team.
50
Detailed information about the data-collecting
instrument was provided in two studies.
32,34
Failure
of the data collector to document episodes of hand-
washing through lapses in observation (missing
observations) was considered in only one study.
34
Who collected data
Data collection was undertaken by a range of staff
with varying levels of expertise in infection control
and skill as observers: graduate nursing students;
research assistants; infection control nurses; and in
one case by a commercial team.
31
Ten studies de-
scribed the training they received.
21,28,31,34,40,
48e50,54,56
Where more than one individual collec-
ted data, inter-rater agreement (inter-rater reli-
ability) was an issue and was assessed in nine
studies; acceptable levels of concordance were re-
ported in each.
16,31,33,35,43,46,48,50,54
In other stud-
ies, discussion of inter-rater reliability suggested
that data collectors had received training,
although this was not mentioned explicitly.
Duration and timing of observation
Observation generally took place for short periods
(30 mine2 h) usually during early shifts on week-
days. Only a few research teams conducted obser-
vation at night.
16,32,33,57
The rationale for the time
and length of observation was provided in 14
studies.
16,19,22,24,31,33e36,40,46,49,50,51
The decision
to restrict observation to day shifts was usually
justied on the grounds that most patient contacts
take place at these times because clinical areas
are at their busiest.
Vantage
Seven studies revealed the vantage of data collec-
tors.
16,22,31,33,40,46,58
They were generally posi-
tioned to monitor health workers entering the unit
and entering and leaving single rooms. Very little in-
formation was provided about the number of health
workers observed by a given number of data
collectors at any one time. Often observation ap-
peared to take place in relation to all heath workers
belonging to the occupational group of interest
present on a ward or unit over the period of data
collection. In one study, health workers were shad-
owed individually to avoid loss of data.
34
The impact of observation on usual
handwashing practice
The effects of observation on the activity being
investigated were rst documented during a series
of productivity experiments at the Hawthorne Elec-
trical Plant in the USA in the 1930s.
59
Researchers
found that productivity increased regardless of the
variable being manipulated. They concluded that
the increase was a direct result of employees being
watched. This nding, now described as the Haw-
thorneeffect has clear implications for observation
studies in which handwashing is being documented,
especially in the present climate where health
workers know that handwashing is being promoted.
In half the studies the authors considered the
possible effect of direct observation on handwash-
ing compliance,
20,22,24,27e31,33e37,40,41,43,45,46,49,58
but detailed discussion of its impact on health-
worker behaviour was offered only by Pittet
et al.
16
During follow-up data collection, these au-
thors deliberately fostered the Hawthorne effect
to promote increased compliance.
In four studies the purpose of research was
known to staff from the outset.
24,33,34,45
In ve
studies health workers were deliberately misin-
formed about the real purpose of the research
throughout.
31,37,58
In the remainder, observation
was covert at least during baseline data collection
or the authors did not state whether staff were in-
formed. In one study, the data collector spent time
in the clinical area before documenting handwash-
ing to acclimatize staff to her presence.
32
Ethical issues
Six authors mentioned obtaining ethical clearance,
but none considered the ethical implications asso-
ciated with intervention studies involving health
workers or conducting close observation involving
patients.
30e32,34,43,51
Discussion
Most studies were narrow in scope. Few contained
enough information about the method of obser-
vation to permit satisfactory evaluation of the
validity and reliability of ndings. Overall, inad-
equate consideration was given to ethical issues.
Measurement of handwashing performance 111
Scope
Less than a quarter of the studies evaluated
handwashing technique, presumably because fre-
quency is much easier to document.
60
Technique
was assessed according to different criteria in
each of the studies in which it was considered, re-
ecting the inadequacy of current standards to
measure it.
60,61
Drying hands is important because
bacteria are transferred more readily between
damp surfaces than dry ones but none of the stud-
ies addressed this issue.
62,63
Many studies were re-
stricted to a single clinical setting. This was usually
a critical care unit. These were also the studies in
which HAI rates were most likely to be included as
outcome measures. However, the critical care set-
ting may not be the best location to examine the
effectiveness of hand hygiene compliance in re-
ducing rates of HAI because many nosocomial in-
fections are endogenous rather than exogenous in
such units.
64
A number of studies involved a single
occupational group or restricted observation to
clinical staff, although all health workers, includ-
ing ancillary staff, handle objects in the near-
patient environment and thus have the potential
to contribute to cross-infection.
65
Validity and reliability
From the limited information about the process of
data collection included in the studies, problems
were apparent in relation to the accuracy of data
collection, the reliability of ndings and the extent
to which they are generalizable to other clinical
settings and occupational groups. Observation is
a skilled activity which cannot be maintained for
any length of time without fatigue and data loss.
66
However, information about the preparation re-
ceived by data collectors was scant, and in many pa-
pers no mention of training was included. Particular
care to observe accurately is needed in busy clinical
areas when vantage is poor (e.g. restricted by bed-
side curtains), especially when several people are
watched simultaneously.
6,12
When observing
a highly specic activity such as handwashing com-
pliance, the very accurate, detailed information
required demands a highly structured method of ob-
serving and documenting data, but this issue was
poorly addressed in the majority of studies.
66
The
possibility of failing to document episodes of hand-
washing was not mentioned except for one account,
where health workers were shadowed individu-
ally.
34
Limited information was offered concerning
the numbers of health workers observed simulta-
neously, although watching several people closely
at the same time is likely to reduce the accuracy
of what is seen and therefore documented. Inter-
rater reliability was discussed in relatively few
studies where it was an issue and glossed over in
every case except for the initiative in Geneva.
16
The rationale used to justify the timing and
length of the observation period was generally
inadequate. Morning shifts during weekdays were
held as the busiest times, when greatest opportu-
nity for patient handling and cross-infection would
occur. However, the majority of studies took place
in critical care units, where nursing care (pressure
area care, changing position) should be performed
regularly over 24 h.
In half the studies researchers acknowledged
that obvious documentation of handwashing can
result ina Hawthorne effect.
59
Someauthors argued
that handwashing is suchaningrainedactivity that it
wouldnot bepossible for healthworkers tomaintain
any changes in usual practice throughout the period
of observation.
5,67
This may have been true in early
studies, but is no longer likely to be the case. Today
health workers knowthat handwashing forms an im-
portant element in quality of care and are likely to
become aware when it is being monitored, whether
or not the attempt is intended to be unobtrusive.
The most frequently used method of trying to avoid
the Hawthorne effect was to undertake observation
covertly. However, it is difcult to accept that se-
crecy was effectively maintained once intervention
had taken place, especially when it involved feed-
back on performance or poster campaigns.
8
Even
attempts to mislead health workers may have had
limited success in avoiding the Hawthorne effect
as the mere presence of an outsider in the research
setting can inuence usual activity.
68
Threats to the validity of direct observation can
be overcome by employing additional methods of
data collection to corroborate or refute ndings.
69
In the case of handwashing there are three possibil-
ities: unobtrusive methods (monitoring devices,
consumption of soap and/or alcohol products);
rates of HAI; and transmission rates of nosocomial
pathogens.
70
The value of unobtrusive methods is
open to debate. Monitoring devices assess only fre-
quency of handwashing: other important aspects
such as technique and appropriateness of the hand
hygiene event cannot be assessed. Monitoring de-
vices need to be tted especially for the study
with resource implications when research budgets
are tight and they sometimes break down.
4,49
Van
de Mortel and Murgo compared the results of alcohol
uptake with direct observation of hand-cleansing
activity.
12
Throughout the period of observation,
use of alcohol products doubled, but direct obser-
vation indicated marked decline in the frequency
of hand cleansing. These authors suggest that
112 D.J. Gould et al.
consumption of alcohol products is a better indica-
tor of compliance than direct observation. How-
ever, spillage, use of some products for purposes
other than hand hygiene and borrowing between
wards has been noted during observation studies.
71
Eckmanns et al. identied a positive correlation
between consumption of hand hygiene products
and hand hygiene compliance.
70
However, neither
of these measures correlated with the incidence
of transmission for ten of the most frequently re-
ported nosocomial pathogens on abraded skin.
70
Few of the studies reviewed incorporated addi-
tional methods of data collection to corroborate
direct observation. Most authors appeared to as-
sume that increasing compliance with handwashing
is a desirable outcome in its own right without
taking into account resource implications such as
the cost of consumables, the time-consuming
nature of traditional washing
72
; the deleterious
effect of repeated washing on skin already in
poor condition
73,74
; or the increased carriage of
potentially nosocomial pathogens.
75
Ethical issues
Where participants in a research study have not
been accurately informed, have been misled or
have not given consent, potentially serious ethical
questions are raised.
76,77
There were numerous
examples of poor practice in which researchers
deliberately provided false information to health
workers or provided incomplete or inaccurate infor-
mation, especially during baseline data collection.
Many infection control teams now regularly docu-
ment handwashing as part of routine infection con-
trol audits,
78
promoting the Hawthorne effect to
increase compliance.
79
If the accuracy and hence
the validity of the methods used to evaluate hand-
washing activity in these initiatives are open to
criticism, ethical issues are raised, because health
workers are being encouraged to change practice
on the basis of faulty and incomplete information.
None of the studies considered the possible
invasion of privacy for patients during observation,
even when non-nursing and medical personnel
collected data.
Recommendations for future research
Handwashing is receiving considerable emphasis
as a straightforward and cost-effective way
of reducing HAI.
2
The number of studies designed
to enhance compliance has doubled since the
publication of the last systematic review.
8
Pittets
work in Geneva has yielded the most promising
results and is described in the greatest detail.
16
It includes some discussion of methodological is-
sues used to obtain observational information.
Other accounts suffer from potentially serious
aws in relation to observation as the method of
data collection and fail to address ethical issues,
reducing the value of the data obtained and the
faith that can be placed in their ndings.
Future studies evaluating the effectiveness of
approaches to increase handwashing compliance
should take place in a range of settings to increase
external validity. Observation in inpatient settings
should be timed to capture a complete picture of
24 h activity and should include all health workers
having closecontact withtheimmediatepatient en-
vironment (bedside, objects frequently handled by
patients or touching them) because all contribute
tocross-infection.
65
Reporteddetails of datacollec-
tion should include: vantage; who collected data;
training received; inter-rater reliability where
more than one person was involved; an indication
of howthe data were documented; and mechanisms
for coping with lost data. Well-conducted studies
will involve more than one method of data collec-
tion in order to corroborate ndings. This is not
possible at present: more research is needed to
establish the most effective approaches. However,
the greatest challenge will be to design intervention
studies which eradicate the Hawthorne effect, yet
avoid violating the rights of health workers and
patients: they should be fully informed about the
purpose of the research.
References
1. Masterton RG, Teare EL. Clinical governance and infection
control in the United Kingdom. J Hosp Infect 2001;47:25e31.
2. Reybrouck G. The role of hands in the spread of nosocomial
infections. J Hosp Infect 1983;4:103e111.
3. Albert R, Condie F. Handwashing patterns in medical inten-
sive care units. N Engl J Med 1981;304:1465e1466.
4. Broughall J, Marshman C, Jackson B, Bird P. An automatic
monitoring system for measuring handwashing frequency
in hospital wards. J Hosp Infect 1984;5:447e453.
5. Sedgewick J. Hand-washing in hospital wards. Nurs Times
1984;80(20):64e66.
6. Gould DJ. Nurses hand decontamination practice: results
of a local study. J Hosp Infect 1994;28:15e30.
7. Taylor LJ. An evaluation of handwashing techniques. Nurs
Times 1978. Part 1 74(2);54e55. Part 2 74(3):108e109.
8. Naikoba S, Hayward A. The effectiveness of interventions
aimed at increasing handwashing in healthcare workers e
a systematic review. J Hosp Infect 2001;47:173e180.
9. Schatzman L, Strauss A. Fieldwork Research. Englewood
Cliffs, NJ: Prentice-Hall; 2001.
10. Bogdan R, Taylor S. Introduction to Qualitative Research
Methods. 2nd edn. New York: Wiley; 2001.
11. Hammersley M, Atkinson P. Ethnography: Principles in
Practice. London: Routledge; 1983.
Measurement of handwashing performance 113
12. Van de Mortel T, Murgo M. An examination of covert observa-
tionandsolutionaudit as tools tomeasurethesuccess of hand
hygiene interventions. Am J Infect Control 2006;34:95e99.
13. Hughes WT, Williams B, Pearson T. The nosocomial colonisa-
tion of T-Bear. Infect Control 1986;7:495e500.
14. McGuckin M, Waterman R, Porten L, et al. Patient education
model for increasing hand washing compliance. Am J Infect
Control 1999;27:309e314.
15. Kaplan LM, McGuckin M. Increasing handwashing compli-
ance with more accessible sinks. Infect Control 1986;7:
408e410.
16. Pittet D, Hugonnet S, Mourouga P, et al. Effectiveness of
a hospital-wide programme to improve compliance with
hand hygiene. Lancet 2000;356:1307e1312.
17. Hugonnet S, Pernager TV, Pittet D. Alcohol-based handrub
improves compliance with hand hygiene in intensive care
units. Arch Intern Med 2002;162:1037e1043.
18. Larson E. APIC Guidelines for hand hygiene and hand anti-
sepsis in health care settings. Am J Infect Control 1995;
23:251e269.
19. Avila-Aguero M, Umalha MA, Jiminez AL. Handwashing prac-
tices in tertiary-care, pediatric hospital and the effect on
an educational program. Clin Perform Qua in Health Care
1998;6:70e72.
20. Bischoff WE, Reynolds TM, Curtis N, Sessler CN, Edward MB,
Wenzel RP. Handwashing compliance by health care
workers: the impact of introducing accessible alcohol-based
hand antiseptic. Arch Intern Med 2000;160:1017e1021.
21. Brown SM, Lubimova AV, Khrustalyeva NM, et al. Use of an
alcohol-based hand rub and quality improvement interven-
tions to improve hand hygiene in a Russian intensive care
unit. Infect Control Hosp Epidemiol 2003;24:172e179.
22. Conly JM, Hills S, Ross J, Lertzman J, Thomas LJ. Hand
washing practices in an ICU: the effects of an educational
program and its relationship to infection rates. Am J Infect
Control 1989;17:330e339.
23. Dorsey ST, Cydulka RK, Emerman CL. Is hand washing teach-
able? Failure to improve hand washing behaviour in an urban
emergency department. Acad Emerg Med 1996;3:360e365.
24. Dubbert PM, Dolce J, Richter W, Miller M, Chapman SW. In-
creasing ICU staff hand washing: effects of education and
group feedback. Infect Control Hosp Epidemiol 1990;11:
191e193.
25. Huang J, Jiang D, Wang X. Changing knowledge, behavior
and practice related to universal precautions among hospi-
tal nurses in China. J Contin Educ Nurs 2002;35:217e224.
26. Muto CA, Sistrom MG, Farr BM. Hand hygiene rates un-
changed by installation of dispensers of a rapidly acting
hand antiseptic. Am J Infect Control 2000;28:273e276.
27. Raju NK, Kobler C. Improving hand hygiene habits in the
newborn nurseries. Am J Med Sci 1991;302:355e358.
28. Rosenthal VD, McCormick RD, Guzman S, Villamayor C,
Orellano PW. Effect of education and performance feed-
back on handwashing: the benet of administrative support
in Argentinean hospitals. Am J Infect Control 2003;31:
85e92.
29. Salemi C, Canola T, Eck E. Hand washing and physicians:
how to get them to together. Infect Control Hosp Epidemiol
2002;23:32e35.
30. Tibbals J. Teaching hospital medical staff to hand wash.
Med J Aust 1996;164:395e398.
31. Whitby M, McLaws ML. Handwashing in healthcare workers:
accessibility of sink location does not improve compliance.
J Hosp Infect 2004;58:247e253.
32. Creedon SA. Health care workers hand decontamination
practices: compliance with recommended guidelines. J Adv
Nurs 2005;51:208e216.
33. Earl ML, Jackson M, Rickman LS. Improved rates of compli-
ance with hand antisepsis guidelines: a three-phase obser-
vational study. Am J Nurs 2001;101:26e33.
34. Gould DJ, Chamberlain A. The use of a ward-based educa-
tional package to enhance nurses compliance with infec-
tion control procedures. J Clin Nurs 1997;6:55e67.
35. Harbarth S, Pittet D, Grady L, et al. Interventional study to
evaluate the impact of an alcohol based hand gel in improv-
ing hand hygiene compliance. Pediatr Infect Dis J 2002;21:
496e497.
36. Maury E, Alzieu M, Baudel JL, et al. Availability of an alco-
hol solution can improve hand disinfection compliance in an
intensive care unit. Am J Respir Crit Care Med 2000;162:
324e332.
37. Mayer JA, Dubbert PM, Miller M, Burkett P, Chapman S. In-
creasing handwashing in an ICU. Infect Control 1986;7:
259e262.
38. Moongtui W, Gauthier D, Turner J. Using peer feedback to
improve handwashing and glove usage among Thai health
care workers. Am J Infect Control 2000;28:365e369.
39. Won SP, Chou HC, Hsiah WS, et al. Hand washing program
for the prevention of nosocomial infections in a neonatal
intensive care unit. Infect Control Hosp Epidemiol 2004;
25:742e746.
40. Coignard B, Grandbastien B, Berrouane Y, et al. Handwash-
ing quality impact of a special program. Infect Control Hosp
Epidemiol 1998;19:510e513.
41. Colombo C, Giger H, Grote C, et al. Impact of teaching
interventions on nurse compliance with hand disinfection.
J Hosp Infect 2002;51:69e72.
42. Lam BC, Lee J, Lau YL. Hand hygiene in a neonatal intensive
care unit: a multimodal intervention and impact on nosoco-
mial infection. Pediatrics 2004;114:565e571.
43. Larson E, McGeer A, Quaraishi ZA, et al. Effect of an auto-
mated sink on hand washing practices and attitudes in high
risk units. Infect Control Hosp Epidemiol 1991;12:422e428.
44. Panhotra BR, Saxena AK, Al-Arabi AM. The effect of a contin-
uous educational program on handwashing compliance
among healthcare workers in an intensive care unit. Br J
Infect Control 2004;5:15e18.
45. Shaw S, Tanner J. Hand washing practices on a neonatal unit:
theinuenceof teachingsessions. J NeoNurs 2003;9:162e166.
46. Bittner MJ, Rich EC, Turner PD, Arnold WH. Limited impact
of sustained simple feedback based on soap and paper
towel consumption on the frequency of hand washing in
an adult intensive care unit. Infect Control Hosp Epidemiol
2002;23:120e126.
47. Swaboda SM, Earsing K, Strauss K, Lane S, Lipsett PA. Elec-
tronic monitoring and voice prompts to improve hand hy-
giene and decrease nosocomial infections in critical care.
Crit Care Med 2004;32:358e363.
48. Larson E, Bryan JL, Adler LM, Lee M, Blane C. Multifaceted
approach to changing hand washing behavior. Am J Infect
Control 1997;25:3e10.
49. Larson EL, Early E, Cloonan P, Surgue S, Parides M. An orga-
nizational climate intervention associated with handwash-
ing and decreased nosocomial infections. Behav Med 2000;
26:14e22.
50. Prieto J, Macleod-Clark J. Contact precautions for Clostrid-
ium difcile and methicillin-resistant Staphylococcus
aureus (MRSA). J Res Nurs 2005;10:511e526.
51. Van de Mortel T, Heyman L. Performance feedback
increases the incidence of hand washing by staff following
patient contact in an ICU. Aust Crit Care 1995;8:8e13.
52. Khatib M, Jamaladdine G, Abdullah A, Ibrahim Y. Handwash-
ing and use of gloves while managing patients receiving
mechanical ventilation in the ICU. Chest 1999;116:172e175.
114 D.J. Gould et al.
53. Diekema DJ, Schult S, Albanese MA, Doebbeling BN. Univer-
sal precautions training of preclinical students: impact on
knowledge, attitudes and compliance. Prev Med 1995;24:
580e585.
54. Baker DJ. Effects of a video based staff training with man-
ager led exercises in residential support. Ment Retard 1998;
36:198e204.
55. Berg DE, Hershaw RC, Claudia AR, Ramirez CA,
Weinstein RA. Control of nosocomial infections in an ICU
in Guatemala City. Clin Infect Dis 1995;21:588e593.
56. Simmons B, Bryant J, Neiman R, Spencer L, Arheart K. The
role of hand washing in preventing endemic ICU infections.
Infect Control Hosp Epidemiol 1990;11:589e594.
57. Graham M. Frequency and duration of hand washing in an
intensive care unit. Am J Infect Control 1990;18:77e81.
58. Donowitz LG. Failure of the overgown to prevent nosoco-
mial infection in paediatric ICU. Pediatrics 1986;77:35e38.
59. Roethlisberger FJ, Dickson WJ. Management and the
Worker. Cambridge, MA: Harvard University Press; 1939.
60. Gould DJ. Hand washing as the basis for infection control.
In: Progressing Antiseptic Development to Reduce Trans-
mission of Antibiotic-resistant Pathogens. Round Table
Series, 84. London: J Royal Soc Med Press; 2006. p. 12e20.
61. Jeanes A. Using alcohol products. Nurs Times 2005;101(28):
28e29.
62. Macintosh C, Hoffman P. An extended model for transfer of
micro-organisms and the effect of alcohol disinfection.
J Hyg 1994;92:345e355.
63. Marples RR, Towers A. A laboratory model for the contact
transfer of micro-organisms. J Hyg 1979;82:237e248.
64. Silvestri L, Petros AJ, SarginsonRE, delaCal ME, MurrayAE, van
SaeneHKF. Hand washing inthe intensive care unit: a big mea-
sure with modest effects. J Hosp Infect 2005;59:172e179.
65. Lucet JC, Rigaud MP, Mentre F, et al. Hand contamination
before and after different hand hygiene techniques: a rand-
omised clinical trial. J Hosp Infect 2002;50:276e280.
66. Swanwick M. Observation as a research method. Nurs Res
1994;2:4e12.
67. Gould DJ. Systematic observation of hand decontamination.
Nurs Stand 2004;18(47):39e44.
68. Homan R. The Ethics of Social Research. London: Longman;
1991.
69. Adler PA, Adler PA. Observational techniques. In:
Denzin NK, Lincoln YS, editors. Handbook of Qualitative
Research. London: Sage; 1994. p. 377e391.
70. Eckmanns T, Scwab F, Bessert J, et al. Hand rub consump-
tion and hand hygiene compliance are not indicators of
pathogen transmission in intensive care units. J Hosp Infect
2006;63:406e411.
71. Gould DJ, Ream E. Assessing nurses hand decontamination
practice. Nurs Times Occasional Paper 1993;89(25):47e51.
72. Voss A, Widmer AF. No time for handwashing? Handwashing
versus alcoholic rub: can we afford 100% compliance? Infect
Control Hosp Epidemiol 1997;18:203e208.
73. Larson E, Killien M. Factors inuencing handwashing behav-
ior of patient care personnel. Am J Infect Control 1982;10:
93e99.
74. Kownatzki E. Hand hygiene and skin health. J Hosp Infect
2003;55:239e245.
75. Larson EL, Norton Hughes C, Pyrek JD, Sparks SM,
Cagstay EU, Bartkus JM. Changes in bacterial ora associ-
ated with skin damage on hands of health care personnel.
Am J Infect Control 1998;26:513e521.
76. Humphreys L. Tearoom trade: impersonal sex in public
places. Chicago: Aldine; 1975.
77. Knight M, Field D. A silent conspiracy: coping with dying
cancer patients on an acute surgical ward. J Adv Nurs
1981;6:221e229.
78. Jeanes A. Establishing asystemtoimprovehandhygienecom-
pliance. Nurs Times Infect Control Suppl 2004;100(5):49e50.
79. Storr J. The effectiveness of the national cleanyourhands-
campaign. Nurs Times 2005;101(8):50e51.
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