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AJN, American Journal of Nursing:
doi: 10.1097/01.NAJ.0000427878.80053.f7
Feature Articles

Original Research: Evaluation of a Hand Hygiene Campaign in Outpatient Health Care Clinics

KuKanich, Kate Stenske PhD, DVM; Kaur, Ramandeep MPH; Freeman, Lisa C. PhD, DVM; Powell, Douglas A. PhD

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Author Information

Kate Stenske KuKanich is an assistant professor in the Department of Clinical Sciences at Kansas State University (KSU) in Manhattan, KS. At the time of this study, Ramandeep Kaur was a graduate student in the Department of Diagnostic Medicine/Pathobiology at KSU, where Douglas A. Powell is a professor. Lisa C. Freeman is vice president for research and graduate studies at Northern Illinois University in DeKalb; at the time of this study, she was a professor and associate dean for research in the College of Veterinary Medicine at KSU. This project was funded by an unrestricted educational grant from the Kansas Health Foundation (BG1551). Contact author: Kate Stenske KuKanich, kstenske@ksu.edu. The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

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Abstract

Objective: To improve hand hygiene in two outpatient health care clinics through the introduction of a gel sanitizer and an informational poster.

Methods: In this interventional study, health care workers at two outpatient clinics were observed for frequency of hand hygiene (attempts versus opportunities). Gel sanitizer and informational posters were introduced together as an intervention. Direct observation of the frequency of hand hygiene was performed during baseline, intervention, and follow-up. A poststudy survey of health care workers was also distributed and collected.

Results: In both clinics, the frequency of hand hygiene was poor at baseline (11% and 21%) but improved significantly after intervention (36% and 54%) and was maintained through the follow-up period (32% and 51%). Throughout the study, postcontact hand hygiene was observed significantly more often than precontact hand hygiene. In both clinics, health care workers reported a preference for soap and water; yet observations showed that when the intervention made gel sanitizer available, sanitizer use predominated. Fifty percent of the surveyed health care workers considered the introduction of gel sanitizer to be an effective motivating tool for improving hand hygiene.

Conclusions: Hand hygiene performance by health care workers in outpatient clinics may be improved through promoting the use of gel sanitizer and using informational posters. Compared with surveys, direct observation by trained observers may provide more accurate information about worker preferences for hand hygiene tools.

The practice of hand hygiene by health care workers, through the use of either soap and water or an alcohol-based hand sanitizer, is widely considered to be the most important and effective means of preventing health care–associated infections. Although numerous studies have demonstrated that hand hygiene reduces health care–associated infection rates,1 adherence to hand hygiene guidelines remains uniformly low among health care workers.2-5 To improve hand hygiene performance and sustain such improvement over time, barriers must be recognized and addressed. These may include poor access to hand hygiene materials, skin irritation, forgetfulness, time constraints, a perception that hand hygiene interferes with worker–patient relationships, lack of knowledge of hand hygiene guidelines, and poor habits learned early in life.6-9

Cleansing the hands with an alcohol-based sanitizer generally takes less time than washing with soap and water. Moreover, when used appropriately, alcohol-based sanitizers have been shown to be more effective than soap and water for eradicating some bacteria.6, 10 For these reasons, both the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) recommend the use of alcohol-based hand rubs or sanitizers for most clinical health care settings.1, 6 However, handwashing with soap and water remains the preferred method when hands are visibly soiled, or when contact with certain infectious agents (such as Clostridium spores and noroviruses) is suspected, as these organisms are highly resistant to killing by alcohol.11-13

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BACKGROUND

Individual health care workers may have different hand hygiene product preferences and may be affected by different motivators and barriers to hand hygiene. Previous interventional studies have determined that a multifaceted campaign, incorporating more than one approach to change, is required to achieve improved hand hygiene practices and sustain them over time.14-17 Such campaigns frequently include the promotion of alcohol-based hand sanitizers; indeed, one hospital-wide study credited the increasing use of such sanitizers as the main reason for improved adherence to hand hygiene guidelines.3 While there is no evidence that posters or other educational materials alone are effective at changing behavior, those that use messages framed in terms of potential gains (rather than losses) and that invoke the health care worker's sense of responsibility for patient health may be beneficial in combination with other strategies.3, 18, 19

Several studies have tested interventions for improving hand hygiene in teaching hospitals and found them to be successful.3, 20, 21 But relatively few studies have tested such interventions in outpatient clinics.22, 23 Mensah and colleagues observed health care workers in outpatient glaucoma clinics in the United Kingdom and found that baseline hand hygiene adherence was 18%.23 After presenting a seminar and distributing a memo addressing this, adherence increased to 28% and was highest among female health care workers and among nurses. In another study conducted at outpatient dermatology clinics in Israel, Cohen and colleagues observed physicians' behavior and sampled their hands for bacteria, but no interventions were introduced.22 Adherence to hand hygiene was low at 31%, and Staphylococcus aureus was isolated from 69% of physicians' hands. In a related survey, another group of physicians cited excessive workloads, lack of awareness, adverse reactions to disinfectants, and lack of hygiene facilities as among the main reasons for lack of adherence.22

Research questions. The primary research questions addressed by our study were as follows:

1. Could an interventional campaign in two outpatient health care clinics lead to improved hand hygiene?

2. Are there differences in the observed frequency of hand hygiene at baseline compared with that at one week and one month after introduction of the intervention?

3. Are there differences in the observed frequency of hand hygiene based on workers' sex, workers' profession, and timing (pre- and postpatient contact)?

4. Which hand hygiene tools do health care workers in these settings prefer?

5. Would the observed health care workers later report that either or both interventional tools were motivating and influenced their hand hygiene habits?

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METHODS

Design and sample. This study used an interventional design, enrolling two outpatient clinics and performing direct observation of health care workers to measure hand hygiene opportunities and attempts at baseline, after the intervention, and during the follow-up period. To recruit the clinics, we first contacted the administration of a large midwestern health care system to determine whether there was mutual interest. Specific outpatient clinics were then chosen from within that system based on willingness to participate, whether the clinic layout would be conducive to direct observation, and whether the anticipated caseload during the study period would be sufficient. Because all observations and surveys were conducted anonymously, after review by the institutional review boards of the researchers' institution and the participating clinics, the study was given exempt status.

The first clinic was an outpatient oncology clinic having an open layout; sinks and foam sanitizers were available at the nurses' station but not in the immediate vicinity of individual patients. The second clinic was an outpatient gastrointestinal (GI) clinic with individual curtained rooms for patients. At each clinic, the observed health care workers included primarily physicians and nurses, as well as a few others. Sinks for handwashing were located at the nurses' station, and foam sanitizer was wall mounted at the entry to each curtained patient room. Gel sanitizer was not available at either clinic.

The intervention consisted of introducing alcohol-based gel sanitizer and a novel poster to each clinic. We included gel sanitizer in this campaign to provide health care workers with an alternative to soap and water and foam sanitizer.

An informational poster was created to increase health care workers' awareness of hand hygiene, provide information about when hand hygiene should be performed, and encourage them to take personal responsibility for reducing the spread of health care–associated infections. To create the poster, clinic administrators, nurse managers, and the research team first brainstormed ideas. Several media consultants from other universities that have conducted similar hand hygiene campaigns also provided input. A first draft was designed and shown to all of these people, and the final version of the poster incorporated their suggested changes for improvement.

Measures. For the purpose of this study, hand hygiene could be acceptably performed using either soap and water or hand sanitizer (foam or gel). We measured the number of hand hygiene attempts against the number of hand hygiene opportunities. Hand hygiene opportunities were defined as those occurring immediately before and after a health care worker makes direct contact with a patient; hand hygiene attempts were defined as an effort to perform hand hygiene during each opportunity. (The term “attempt” was used rather than “compliance,” because we did not monitor hand hygiene technique for compliance with guidelines.) Direct observers monitored the opportunities and recorded the attempts. To establish intercoder reliability prior to the study, two observers were trained and then asked to observe and record the same hand hygiene opportunities; the overall percentage agreement between the observers was 96%. For the GI clinic, only those opportunities and attempts that gave observers full visibility through an open or partially open curtain were monitored and recorded.

Baseline data were collected on three nonconsecutive days, for four hours each day. Then approximately 10 pump bottles of gel sanitizer containing 65% ethyl alcohol were provided in each clinic on the nurses' station counter. The counters were long, extending the lengths of the clinics, and the bottles were spaced out so they lined up with patient areas or rooms as closely as possible. Twenty posters were strategically placed near sinks, at intervals along the nurses' station counter, and next to wall-mounted foam sanitizer dispensers. One influential physician in the GI clinic was displeased when the posters were hung, expressing concern that the tape used to mount them would damage the clinic's walls; the posters were rehung with painter's tape to ease his concern and prevent damage (the study design was not altered).

One week after the introduction of the intervention, direct observation of hand hygiene was performed on five nonconsecutive days, for four hours each day. This design allowed evaluation of the impact of a short intervention period. After these interventional observations were complete, the posters were removed at the request of the clinics' administration. The remaining gel sanitizer was left behind, but it too was removed by the administration, in keeping with the clinics' policy. One month after the last day of the interventional observations, follow-up direct observation of hand hygiene was done on three nonconsecutive days, for four hours each day. Neither posters nor gel sanitizers were provided during the follow-up period.

A survey was mailed to the nurse managers at both clinics and was distributed to 47 health care workers at the oncology clinic and to 41 health care workers at the GI clinic, three months after the last day of the follow-up observations. The survey was conducted to evaluate the workers' perceptions of the hand hygiene campaign, its motivational impact on their hygiene practice, perceived barriers to hand hygiene at their clinics, and their preferred hygiene tools (soap and water, foam sanitizer, or gel sanitizer). A five-item Likert scale (ranging from “strongly disagree” to “strongly agree”) was used for questions regarding the motivational efficacy of the intervention tools.

Analytic strategy. Pearson's χ2 analyses were used to compare the frequency of hand hygiene attempts during the three observation periods and to compare the precontact and postcontact frequency of such attempts. Each calculation had 1 degree of freedom. A P value less than or equal to 0.05 was considered significant. Only descriptive statistics were used to assess hand hygiene frequency by workers' sex and profession, because there were too few observations of male health care workers and physicians to permit comparative analyses. Descriptive statistics were also used for comparing the hand hygiene tools used, as product availability varied throughout the study. Because most observed health care workers were nurses and physicians, other health care workers were excluded from data analysis.

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RESULTS

While the number of health care workers varied from day to day and from clinic to clinic, on average five nurses and three physicians were observed per day in the oncology clinic, and eight nurses and four physicians were observed per day in the GI clinic. In both the oncology and GI clinics, at baseline, the overall rates of hand hygiene attempts to opportunities were low (11% and 21%, respectively); these improved significantly after the intervention was instituted (36% and 54%, respectively), and remained improved at the one-month follow-up period (32% and 51%, respectively) (see Table 1). Throughout the study, female health care workers demonstrated more consistent hand hygiene than their male counterparts, and nurses demonstrated more consistent hand hygiene than physicians (see Table 2).

Table 1
Table 1
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Table 2
Table 2
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A total of 56 health care workers returned surveys (41 from the oncology clinic, 15 from the GI clinic). Fifty percent of all survey respondents agreed or strongly agreed that the campaign had increased their awareness about hand hygiene, with more workers at the GI clinic (80%) reporting this belief than at the oncology clinic (39%). Overall, 34% of all respondents agreed that the hand hygiene campaign had improved their hand hygiene practices.

At the oncology clinic, the usage rates for soap and water and foam sanitizer were almost equal at baseline (53% and 47% of attempts, respectively). But after the intervention's introduction of gel sanitizer, these usage rates dropped (to 21% and 40%, respectively). Gel sanitizer was used in 40% of hand hygiene attempts. During the follow-up observation period, the gel sanitizer provided by the researchers was removed. The usage rate for soap and water remained low (24%) while that for foam sanitizer rose (63%). Self-provided gel sanitizer was used also (13%). At the GI clinic, the baseline usage rate for foam sanitizer (59%) was higher than that for soap and water (40%). After the intervention's introduction of gel sanitizer, the usage rates for soap and water and foam sanitizer dropped (to 19% and 40%, respectively); gel sanitizer was used in 41% of hand hygiene attempts. During the follow-up period, the usage rate for soap and water remained low (34%), while that for foam sanitizer increased (62%). Self-provided gel sanitizer was used also (4%). (Some percentages don't sum to 100 because of rounding.)

Of the 56 survey respondents, 50% agreed or strongly agreed that the introduction of gel sanitizer was an effective motivator and led to improved hand hygiene frequency. Asked “Which do you prefer most as a means of hand hygiene?” the 41 respondents from the oncology clinic reported mixed preferences (soap and water, 58%; foam sanitizer, 24%; gel sanitizer, 22%), whereas 80% of the 15 respondents from the GI clinic reported a preference for soap and water, with the remainder preferring foam sanitizer (20%) and gel sanitizer (20%). (Percentages don't sum to 100 because some responders at both clinics reported preferences for more than one hand hygiene tool.) Asked “What is the most suitable place to keep sanitizer, to make its use more effective?” 66% of all respondents preferred placement in the immediate vicinity of the patients.

In the GI clinic, 93% of the 15 surveyed health care workers reported being aware of the new posters; of these, 36% agreed or strongly agreed that the posters were effective as a motivational tool for encouraging hand hygiene. In the oncology clinic, 49% of the 41 surveyed workers reported being aware of the posters, and of these, 45% agreed or strongly agreed that they were effective. Among all survey respondents, 42% reported finding neither the introduction of gel sanitizer nor the poster motivating, while 23% were motivated by both interventional tools.

Perceived barriers to hand hygiene among all survey respondents included “skin irritation” (34%), “forgetfulness” (32%), “insufficient time” (24%), “interference with patient care” (11%), “lack of facilities or inaccessible materials” (5%), and “insufficient training” (5%); some respondents selected multiple barriers. Twenty-three percent reported that none of the above was a barrier in their clinic. Although no objective data were collected to assess the incidence of skin irritation associated with use of the available hygiene tools, numerous health care workers in both clinics were overheard commenting during both observation periods that the gel sanitizer was less irritating than either the foam sanitizer or soap and water.

At baseline, the frequency of observed hand hygiene attempts was greater after patient contact than before patient contact (P = 0.001 in oncology clinic, P = 0.002 in GI clinic). This was also the case at one week after the intervention (P > 0.001 in each clinic) and during the follow-up observation period (P > 0.001 in each clinic). Hand hygiene improved from baseline to the intervention period for precontact and postcontact observations, and this improvement was sustained with no significant decreases in hygiene in both clinics during the follow-up period. A similar finding was seen in the survey responses (n = 53 for this question): more respondents reported “always” performing hand hygiene after contact with patients (83%) than reported “always” performing hand hygiene before contact with patients (57%).

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DISCUSSION

The study findings indicate that the frequency of hand hygiene by health care workers in busy outpatient health care settings is low, and that short-term exposure to interventional tools can lead to modest improvement still evident at one-month follow-up. Among our survey respondents, individual responses to the motivational effectiveness of the posters or gel sanitizer varied, suggesting that pretesting interventions in a given clinic and using a multifaceted implementation approach might help to achieve the greatest improvements. Establishing or reinforcing a clinic-wide expectation that health care workers will adhere to hand hygiene recommendations is another measure that may further promote such adherence.1, 3, 23 Modeling and support of proper hand hygiene from clinic leaders (such as physicians and nurse managers) have also been suggested as important factors for improving hand hygiene.1, 3, 24 In our study, the lower frequency of hand hygiene among physicians at baseline—and, at the GI clinic, the negative attitude of one influential physician toward the posters—might have contributed to the relatively modest overall improvement in hygiene among all health care workers. This also supports the need to encourage the involvement and investment of clinic leaders in future hand hygiene campaigns.

To minimize spread of infection, CDC guidelines recommend that hands be washed or sanitized immediately before and after every direct contact with a patient.6 At both clinics, observations showed that hand hygiene performance was consistently better after patient contact than before patient contact; this trend was also supported by the survey responses. These findings are consistent with those of other studies.9, 25, 26 Asked why health care workers tend to “practice better hygiene after patient contact than before patient contact,” our survey respondents named several possibilities, including a belief that self-protection is a priority, a sense that patient contact acts as a reminder to perform hygiene, and a belief that postcontact hygiene for one patient serves as adequate precontact hygiene for the next. Findings from other studies also support the idea that self-protection acts as a strong motivator for hand hygiene.9, 25 This suggests that future campaigns should focus on encouraging health care workers to take personal responsibility in a more clinic-specific, patient safety–oriented approach.19, 25

Most survey respondents reported a preference for soap and water over either type of sanitizer. This reported preference may stem from previous training or from a belief that soap and water is the best method of hand hygiene and therefore the “correct” answer on a survey. Currently, both the CDC and the WHO recommend handwashing with soap and water when hands are visibly soiled with blood or other body fluids and after contact with certain infectious organisms, including clostridial spores and norovirus; but both recommend using an alcohol-based sanitizer for all other clinical situations.1, 6, 11, 12 Future campaigns should emphasize these recommendations. Despite our survey respondents' reported preference for soap and water, we observed health care workers using sanitizer (gel, foam, or both) more often than soap and water once gel sanitizer was made available at the clinics. Possible causal factors include increased access to gel sanitizer during the intervention, convenience, faster usage time, and a perceived decrease in skin irritation. After administrators removed gel sanitizer from the clinics, some health care workers began carrying gel sanitizer in their pockets for personal use, suggesting an ongoing preference. This discrepancy between self-reported preferences and actual observed practice suggests that there are many factors and potential barriers that influence hand hygiene performance. To improve adherence, the CDC recommends providing a variety of hand hygiene products, routinely performing direct observation of hygiene performance, and monitoring product usage.6

The primary barriers to hand hygiene reported by our survey respondents were skin irritation, forgetfulness, and insufficient time, and these are similar to those reported by others.7, 8, 22, 27 The consistency, smell, and content (some products contain aloe, a moisturizer) of soaps and sanitizers can also influence adherence. During the interventional and follow-up observation periods, health care workers at both clinics were overheard discussing their preference for gel over foam sanitizer, feeling that the gel was less irritating to their skin; it's possible that these workers might cleanse their hands more frequently if gel sanitizer were available. Outpatient clinic administrators should consider health care worker preferences as well as product costs when deciding which to purchase. Placing hand sanitizer in the immediate vicinity of patients (such as at or near the entrances to patient rooms) can both save time and serve as a visual reminder of the need to lower the risk of health care–associated infection.

The poster was designed to improve hand hygiene by increasing awareness, providing information, and encouraging health care workers to take personal responsibility for reducing the spread of infection. Reasons for its limited effect might include a lack of support from influential health care workers, sex differences, and ineffective poster design. The influential physician who was displeased with poster placement in his clinic may have negatively swayed other health care workers, thus hindering the campaign's overall impact. The effect of workers' sex on hand hygiene might also have been a factor. There is evidence that men and women respond differently to health promotion messages: women may be more motivated by knowledge-based messages that remind them why hand hygiene is important, whereas men may be more motivated by messages that elicit emotions such as disgust.23, 28 Involving clinic staff in poster design and messages, designing posters to be more clinic-specific, periodically providing posters with new messages, and positioning posters near both hand hygiene materials and patients may also help health care workers to feel more involved in and committed to a hand hygiene campaign.

Limitations and recommendations for further research. One limitation of this study is the possibility of the Hawthorne effect; some health care workers might have realized that they were being observed and cleansed their hands more frequently as a result. While using video cameras or training staff in covert observation might have minimized this possibility, the clinic layouts, time constraints, and the need to ensure patient privacy made such solutions less than desirable. To minimize possible bias, only clinic administrators, nurse managers, and medical directors were consulted regarding study design. The possibility of the Hawthorne effect notwithstanding, we recommend that future researchers, after collecting baseline data, seek the ongoing support and involvement of influential health care workers, who can also serve as role models for others.

Another limitation is that observations weren't tagged with health care workers' identities. It's possible that workers with excellent hand hygiene habits were observed with greater frequency than those with poor habits, thus skewing the data and the statistical analysis. Although health care workers probably prefer to remain anonymous during such observations, we recommend recording and associating worker identities with hygiene performance so that statistical analyses can be as accurate as possible.

Because resource limitations led to interventional and follow-up observation periods of different durations, and because of fluctuating patient caseloads during these periods, not all health care workers had the same number of opportunities for hand hygiene; future studies could schedule additional observation periods in order to achieve more equal sample sizes. Finally, leaving interventions in place for a longer time period and extending follow-up observations beyond one month (to three, six, and 12 months) would be useful in evaluating whether the interventions had sustained effects.

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CONCLUSIONS AND PRACTICE IMPLICATIONS

This hand hygiene campaign showed that introducing a gel sanitizer and providing informational posters can yield modest short-term improvements in overall hand hygiene performance in outpatient clinics. To maximize the clinical impact of such a campaign, we suggest that administrators and influential health care workers work together to create an environment in which adherence to hand hygiene is expected; provide a variety of hand hygiene products—including gel sanitizer in either pocket-size or pump dispensers—in the immediate vicinity of patients; and encourage health care workers to create several motivational, setting-specific posters that can be rotated throughout the clinic on a regular basis. The findings of this study should also prompt increased attention to precontact hygiene in outpatient clinics, in order to minimize the potential spread of infection. Indeed, the intermittent evaluation of hand hygiene, using direct observation, is essential for identifying aspects that need improvement and maintaining adherence as a top priority.

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REFERENCES

1. World Health Organization. WHO guidelines on hand hygiene in health care. Geneva, Switzerland; 2009. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf.

2. Graham M. Frequency and duration of handwashing in an intensive care unit Am J Infect Control. 1990;18(2):77–81

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9. Whitby M, McLaws ML. Handwashing in healthcare workers: accessibility of sink location does not improve compliance J Hosp Infect. 2004;58(4):247–53

10. Lilly HA, Lowbury EJ. Transient skin flora: their removal by cleansing or disinfection in relation to their mode of deposition J Clin Pathol. 1978;31(10):919–22

11. Centers for Disease Control and Prevention. Norovirus in healthcare settings. 2010. http://www.cdc.gov/HAI/organisms/norovirus.html.

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13. Liu P, et al. Effectiveness of liquid soap and hand sanitizer against Norwalk virus on contaminated hands Appl Environ Microbiol. 2010;76(2):394–9

14. Lankford MG, et al. Influence of role models and hospital design on hand hygiene of healthcare workers Emerg Infect Dis. 2003;9(2):217–23

15. Naikoba S, Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers—a systematic review J Hosp Infect. 2001;47(3):173–80

16. Vietri NJ, et al. The effect of moving to a new hospital facility on the prevalence of methicillin-resistant Staphylococcus aureus Am J Infect Control. 2004;32(5):262–7

17. Whitby M, et al. Three successful interventions in health care workers that improve compliance with hand hygiene: is sustained replication possible? Am J Infect Control. 2008;36(5):349–55

18. Gould DJ, et al. The CleanYourHandsCampaign: critiquing policy and evidence base J Hosp Infect. 2007;65(2):95–101

19. Jenner EA, et al. Hand hygiene posters: selling the message J Hosp Infect. 2005;59(2):77–82

20. Bischoff WE, et al. Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic Arch Intern Med. 2000;160(7):1017–21

21. McGuckin M, et al. The effect of random voice hand hygiene messages delivered by medical, nursing, and infection control staff on hand hygiene compliance in intensive care Am J Infect Control. 2006;34(10):673–5

22. Cohen HA, et al. Handwashing patterns in two dermatology clinics Dermatology. 2002;205(4):358–61

23. Mensah E, et al. Hand hygiene in routine glaucoma clinics Br J Ophthalmol. 2005;89(11):1541–2

24. Pittet D, et al. Hand hygiene among physicians: performance, beliefs, and perceptions Ann Intern Med. 2004;141(1):1–8

25. Bahal A, et al. Hand hygiene compliance: universally better post-contact than pre-contact in healthcare workers in the UK and Australia British Journal of Infection Control. 2007;8(1):24–8

26. Whitby M, et al. Why healthcare workers don't wash their hands: a behavioral explanation Infect Control Hosp Epidemiol. 2006;27(5):484–92

27. Voss A, Widmer AF. No time for handwashing!? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol. 1997;18(3):205–8

28. Judah G, et al. Experimental pretesting of hand-washing interventions in a natural setting Am J Public Health. 2009;99(Suppl 2):S405–S411

For 34 additional continuing nursing education articles on research topics, go to www.nursingcenter.com/ce.

Keywords:

hand hygiene; hand sanitizer; health care–associated infection; outpatient clinic; poster

© 2013 Lippincott Williams & Wilkins, Inc.

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