An evaluation of the efficacy of observational hand hygiene auditing: a mixed methods approach

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Smiddy, Maura P.
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University College Cork
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Background and aim: Healthcare-associated infection (HCAI) causes morbidity and mortality worldwide. Compliance with hand hygiene guidelines reduces the risk of acquiring a HCAI however, compliance is often substandard and poorer amongst doctors than other healthcare workers. Observational hand hygiene auditing (OHHA) monitors healthcare worker compliance with the World Health Organization “5 moments for hand hygiene” and has been shown to improve hand hygiene compliance. There are methodological issues regarding audit implementation such as the impact of the Hawthorne effect, observer bias and selection bias. Also, there are questions regarding what aspects of OHHA implementation influence the efficacy of the intervention. The aim of this thesis was to conduct a pragmatic evaluation of the application and impact of OHHA on hand hygiene compliance in healthcare focussing on a national, local and individual perspective. Methods: This thesis uses a Logic Model Framework with mixed methodologies to evaluate the application and impact of OHHA. Evaluation logic models assist in tracking, monitoring and determining progress of research evaluation programmes. The logic model provided an integrative framework design incorporating both quantitative and qualitative methods in the evaluation. The model provided the framework to integrate the different research studies in a cohesive way to gain a cumulative understanding of the overall findings. The first study was a systematic review of qualitative research on healthcare workers’ compliance with hand hygiene guidelines. This review informed the theoretical development of the thesis and provided context for the OHHA intervention within the healthcare setting. The second study described the quantitative impact of an OHHA intervention without individualised feedback at a national level. The next quantitative paper provides an evaluation of the impact of OHHA with individualised feedback in a single site. The findings of this paper were not fully explained by the quantitative data and so using a mixed methods sequential explanatory design a qualitative study was designed using the Theoretical Domains Framework to explore the quantitative findings. Results: The review of the qualitative literature identified two main themes which influenced healthcare workers’ compliance with hand hygiene guidelines: motivational factors and perceptions of the work environment. Information was one aspect of the work environment theme and was related strongly to hand hygiene audit and feedback. Audit and feedback were viewed as an important part of improving practice. This review also identified that many qualitative studies were lacking in theoretical frameworks to support the rigour and quality of the study. A time series analysis of the effect of a national intervention, without individualised feedback, on outcome variables showed that OHHA positively influences hand hygiene behaviours. A significant increase in alcohol based hand rub procurement (p>0.05) was observed but this did not translate to a reduction in bloodstream infection. A single centre time series analysis of OHHA with individualised feedback to doctors showed observed hand hygiene compliance increased significantly among both orthopaedic surgeons and consultant doctors (p<0.05). The analysis of the explanatory qualitative paper with doctor participants identified eight domains of the Theoretical Domains Framework that were relevant to the twelve emerging themes. The five dominant domains were (i) Behavioural Regulation was apparent throughout the findings; receiving written individualised audit feedback positively influenced practice; (ii) Knowledge: provision of specific individualised feedback increased hand hygiene knowledge and improved performance; (iii) Reinforcement: doctors agreed that audit identified substandard practices which need to be addressed at a senior level; (iv) Social Professional Role and Identity: doctors found audit reports triggered profession associated competitive motivation and were also useful evidence of good clinical practice; (v) Environmental Context and Resources: auditing was perceived to be synonymous with a strong organisational safety culture. The findings are integrated using the, dominant domains of the Theoretical Domains Framework, identified in chapter six and provide a framework for future intervention implementation and evaluation. Conclusion: This thesis provides critical evidence on interventions which can positively influence OHHA efficacy in a real-world setting. An individualised audit and feedback intervention was effective in improving observed hand hygiene compliance. Incorporation of OHHA with individualised feedback into routine daily practice needs to be considered as a quality improvement opportunity. This thesis contains practical recommendations to guide future research and practice.
Observational hand hygiene audit , Hand hygiene , Compliance , Behaviour
Smiddy, M. P. 2018. An evaluation of the efficacy of observational hand hygiene auditing: a mixed methods approach. PhD Thesis, University College Cork.