Share this article on:

Hand Washing: So Simple, So Complex

Abell, Virginia Louise RN, BA, CIC

Infectious Diseases in Clinical Practice: May 2009 - Volume 17 - Issue 3 - p 133
doi: 10.1097/IPC.0b013e3181a4911b
Editorial Comment

From the Infection Control, Summa Health System, Akron, OH.

Reprints: Virginia Louise Abell, RN, BA, CIC, Infection Control, Summa Health System, 525 E Market St, PO Box 2090, Akron, OH 44309-2090. E-mail:

"Wash your hands"-an admonishment heard since childhood. Mothers have extolled the virtues of clean hands for generations. Hand washing is a basic tenet of infection prevention strategies. Infection prevention and control educators teach health care workers (HCWs) that hand washing reduces the risk of infection.1 Hand washing is the first and the last step in an extensive (seemingly endless) list of nursing procedures.2 The relatively simple task of hand washing takes on complexity in the hospital environment. Questions arise among HCWs and researchers regarding hand washing: Where? When? What products? For how long? How often? How is compliance? A hand hygiene program has developed. Hand hygiene encompasses antiseptic hand rubs, designed for waterless use, and hand washing with plain or antimicrobial soap and running water.

The 2002 Centers for Disease Control Guideline for Hand Hygiene in Healthcare Settings,3 a 45-page document with 423 references, is a testament to this complexity. The guideline is the work of the Healthcare Infection Control Practices Advisory Committee and the Healthcare Infection Control Practices Advisory Committee/Society for Healthcare Epidemiology of America/Association of Professionals in Infection Control and Epidemiology/Infectious Disease Society of America Hand Hygiene Task Force. The Centers for Disease Control guideline reviewed the scientific data regarding hand hygiene and made recommendations regarding indications for hand washing, hand hygiene techniques, selection of hand hygiene agents, HCW educational and motivational programs, and administrative measures. In addition, the guideline encourages researchers to investigate strategies for improving compliance to the recommendations. A specific topic suggested for research was the assessment of the key determinants of hand hygiene behavior and promotion among different populations of HCWs.

Hassan et al4 completed just such an assessment of hand hygiene behavior. "Understanding Hand Hygiene Behavior Among Jordanian Registered Nurses: an Application of Theory of Planned Behavior" is published in this issue of Infectious Diseases in Clinical Practice. The theory of planned behavior (TPB) is a theory about the association of attitude and behavior. Hassan et al note numerous applications of TPB in the health care field. The study supported a relationship between the variables of TPB and intention to comply with hand hygiene. Findings included significant difference in intention toward hand hygiene between the age groups of nurses working in different departments (intensive care units and medical surgical wards). Also, attitude and beliefs about outcome varied among nurses in different departments. This study applied TPB in an interesting and significant manner. The theory of planned behavior factors are based on cognitive factors, such as ability, skills, and information. It is possible that some behavior-predicting factors have been overlooked. Dutta-Bergman and Mohan5 emphasize the importance of personal emotion and affective processing in health-related behavior. These factors could include threat, fear, and mood. Hassan et al discuss the need for more study to identify the factors that influence compliance with hand hygiene recommendations. Consideration of the behavioral links to hand hygiene compliance is a useful approach. It allows for critical analysis that could lead to recommendations for education, interventions, and further research.

Back to Top | Article Outline


1. Larson EL. APIC guideline for hand washing and hand antisepsis in health care settings. Am J Infect Control. 1995;23:251-269.
2. Perry AG, Potter PA, eds. Clinical Nursing Skills and Techniques, 6th ed, St. Louis, MO: Elsevier Mosby; 2006.
3. Centers for Disease Control and Prevention. Guideline for hand hygiene in health-care settings. Morbidity and Mortality Weekly Report. 2002;51:1-44.
4. Hassan Z, Wahsheh M, Hindawi O. Understanding hand hygiene behavior among Jordanian Registered Nurses: an application of theory of planned behavior. Infectious Diseases in Clinical Practice. 2009.
5. Dutta-Bergman, Mohan J. (2005). Theory and practice in health communication campaigns: a critical interrogation. Health Communication, 18 (2), 103-122. Available at: Accessed February 22, 2009.
© 2009 by Lippincott Williams & Wilkins.