The Journal of Continuing Education in the Health Professions, Volume 26, pp. 244-251. Printed in the U.S.A.

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Alliance for Continuing Medical Education, the Society for Medical Education, the Society for Academic Continuing Medical Education, and
the Council on CME, Association for Hospital Medical Education. All rights reserved.

Review

Improving Adherence to Hand Hygiene Among

Health Care Workers
Courtney Maskerine, BHSc; and Mark Loeb, MD
Abstract
Increased adherence to hand hygiene is widely acknowledged to be the most important way of
reducing infections in health care facilities. Despite evidence of benefit, adherence to hand
hygiene among health care professionals remains low. Several behavioral and organizational
theories have been proposed to explain this. As a whole, the success of interventions to improve
adherence to hand hygiene among health care professionals has been limited. Recent data sug-
gest that a multifaceted intervention, including the use of feedback, education, the introduction
of alcohol-based hand wash, and visual reminders, may increase adherence to hand-hygiene
recommendations. Although the “active ingredient” of such an intervention is unknown, there
is evidence that the use of feedback may be the key to increasing adherence. In this article, we
review the theoretical basis for interventions and provide an overview of the evidence for inter-
ventions. Coherent and methodologically sound research is required to better understand the
factors contributing to hand-hygiene behavior among health care professionals.
Key Words: Hand hygiene, infection, health care workers, behavioral theory, continuing
medical education, intervention

Introduction preventable through improved hand hygiene.9

Potential bacterial pathogens often reside on the
Hospital-acquired infections, including those skin of colonized patients. Health care profes-
caused by antibiotic-resistant organisms, occur sionals who touch the skin of patients while pro-
in up to 10% of hospitalized patients.1,2 Not only viding direct care may transiently harbor the
does this lead to increased morbidity and mor- organism on their hands.10 If they do not wash
tality among patients, it also results in a substan- their hands between seeing patients, health care
tial economic burden to health care facilities.3 It professionals can transfer the antimicrobial-
is widely accepted that compliance with hand resistant bacteria to other patients. There is evi-
hygiene among health care professionals is a key dence dating back to 1847, when reduced deaths
factor in reducing the spread of antimicrobial- were noted among postdelivery mothers cared
resistant bacteria and nosocomial infections.4–8 for by staff who cleaned their hands with an anti-
In fact, it is estimated that between 15% and septic soap, to justify why hand hygiene is con-
30% of nosocomial infections are considered sidered the cornerstone of hospital infection
control.5
Despite the evidence to support its benefit,
Ms. Maskerine: Faculty of Health Sciences, McMaster adherence to hand hygiene among health care
University; Dr. Loeb: Departments of Pathology & Molecular professionals remains low. Improving adherence
Medicine and Clinical Epidemiology & Biostatistics,
McMaster University, Hamilton, Ontario, Canada. to hand hygiene remains one of the most impor-
tant but elusive goals of infection control. In a
Correspondence: Mark Loeb, MD, McMaster University,
Room 3200 MDCL, 1200 Main St. West, Hamilton, Ontario, number of reports, adherence has been estimated
Canada; e-mail address: loebm@mcmaster.ca. to range from 30% to 60% in the absence of any
The Journal of Continuing Education in the Health Professions, Vol. 26 No. 3, Summer 2006
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244
 Maskerine et al.

intervention.11 Moreover, it has been demon- health care workers (mainly physicians and
strated that adherence worsens with activities nurses) in the hospital setting and assessed inter-
that place patients at higher risk for infection.12 ventional strategies including audit and feed-
This occurs despite the fact that hand washing back, educational materials, visual reminders,
with soap and water is no longer the only option provision of soaps or antiseptics, or multifaceted
for decontaminating hands. Hand rubs con- approaches) that assessed outcomes including
taining 70% alcohol are quick (requiring 10 to hand-hygiene compliance and nosocomial infec-
20 seconds) and decontaminate hands from tion rates. We included review articles, observa-
pathogens such as Staphylococcus aureus, tional trials, and articles in the reference list of
Pseudomonas aeruginosa, and other pathogens retrieved citations. We excluded studies evaluat-
more effectively than soap and water.13 ing microbiologic outcomes. The theories dis-
When asked, health care workers report a cussed include those around individual change
number of barriers to adherence with hand- management and environmental or systems fac-
hygiene practice recommendations, including tors. Although many psychological theories
skin irritation caused by hand-hygiene products, exist, we focused on those that have been evalu-
inaccessible hand-hygiene supplies, forgetful- ated in multiple settings and explain behavior in
ness, lack of knowledge of the guidelines, and terms of factors that are amenable to change.
insufficient time for hand hygiene.14–20 Self-per-
ceived reasons for nonadherence to hand hygiene Psychological Theories and Behavioral
vary among different types of health care work- Change
ers and between different sites.10 Many hospitals
now place hand-hygiene supplies outside patient Several theories have been suggested to explain
rooms, making accessibility less of a barrier. nonadherence to hand-hygiene practices among
Forgetfulness and lack of knowledge are 2 poten- health care workers. For example, according to
tially modifiable factors that can be targeted by the health belief model, a health care worker’s
performance feedback. However, whether target- actions depend on the perceived susceptibility of
ing such perceived barriers is actually important the health threat, the perceived severity of the
in increasing adherence is uncertain. threat, and the belief that a particular health rec-
Interventions are required to improve the ommendation would be beneficial without
application of evidence by health care workers costly barriers or high risks.20 Thus, according to
and thereby improve hand hygiene. Current this theory, health care workers would adhere to
intervention strategies have focused on educa- hand hygiene if they believed that they were sus-
tional, behavioral, and organizational interven- ceptible to a particular infection and would
tions, alone or in combination. In this article, we acquire this infection if they did not wash their
will review both the theoretical basis for and the hands. Although this may occur for certain types
effects of strategies that have been previously of infections, such as viral infections, for bacte-
undertaken to promote hand hygiene. Factors rial infections, this is generally not the case. The
that influence evidence application will be dis- theories of reasoned action and planned behavior
cussed to determine means by which current are based on the assumption that people make
hand-hygiene interventions may be improved. rational decisions based on systematic use of
For this narrative review, we conducted a available information and also consider the
MEDLINE search of English-language articles implications of actions before engaging in the
published between 1962 and 2004 using the term behavior.20 These theories suggest that a health
“hand hygiene” along with a search of related care worker who believes that a behavior will
Cochrane reviews. We focused studies about lead to positive outcomes, such as adherence to

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 Maskerine et al.

hand hygiene preventing infection in patients, librium, monitoring the success of the strategies
will hold a favorable attitude. Self-efficacy they have used to deal with the health problem.22
expectancies are beliefs about one’s abilities to In contrast, adult-learning theories center on the
perform the behavior (eg, “I can wash my hands need to experience problems with hand hygiene
consistently before and after seeing patients”) in order to be motivated to change hand-washing
and, based on empirical evidence from studies of behaviors.23 These theories are grounded in the
organizational behavior, may be one of the most belief that individuals strive to achieve profes-
important factors related to behavior change.20 sional competence.
The transtheoretical model focuses on how to Several theories also support the idea that
facilitate intentional change, viewing health nonadherence may be explained in the context of
behavioral change as a series of gradual, contin- health care teams. Social influence theories indi-
uous stages. Such a “stages-of-change” theory cate that social norms are important determi-
has recently been proposed as a model to nants of hand-washing practices; therefore,
improve hand hygiene among health care work- emphasis is placed on the need for leadership,
ers.21 This model characterizes particular stages communication, support, role modeling, and
and provides guidance as to how best to help feedback.23 Marketing theories suggest that
participants become aware of the need for hand hygiene is affected by a product or mes-
change, contemplate and prepare for change, sage being disseminated to a target group.
and act and maintain that change. It has been Marketing approaches attempt to tailor the mes-
suggested, therefore, that education-based pro- sage to the needs of the target group and to iden-
grams may not be successful for improving tify and overcome the barriers to change.23
adherence to hand hygiene because they have
not addressed health care workers’ psychologi- Organizational Change
cal preparedness for change, beliefs in their abil-
ity to change, or the relevance of actually Total quality improvement strategies, developed
changing their behavior.21 by industry, are a broad class of organizational
In addition to motivational and stage-of- or system strategies that would suggest that non-
change models, there are also action theories compliance with hand-hygiene practices is
such as operant conditioning that propose that attributable to a system failure, rather than the
behaviors that have perceived positive conse- lack of knowledge or motivation. Such total
quences are more likely to be repeated.22 This quality improvement approaches are character-
principle is widely established and may be appli- ized by “plan-do-study-act” cycles. These are
cable to hand hygiene, such as providing a not specific interventions but general approaches
reward to health care workers “caught” in the act to improving quality.24 A review of clinical
of washing their hands. Such behavioral theories guideline implementation indicated that system-
suggest that hand-washing behaviors are influ- atic reviews have focused on individual clini-
enced predominantly by external stimuli and are cians’ behaviors, failing to recognize the
therefore susceptible to feedback, incentives, importance of developing and maintaining sup-
modeling, and reinforcement.23 For health care portive health care systems.25 However, many
workers who maintain poor hand-washing systematic reviews implicitly acknowledge the
habits, lack of coercion or pressure to change effects of organizational structure on the ability
their behavior may enable poor hand hygiene. to adopt guidelines. A modified Delphi process
The self-regulatory model is another action was used to elicit information from med-
theory. This model proposes that individuals use ical groups at the Institute for Clinical Sys-
preexisting knowledge to restore their own equi- tems Improvement (ICSI), Minneapolis, on the

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 Improving Hand Hygiene Among Health Care Workers

factors that they perceived to be important in behavior. For example, in a study to determine the
guideline implementation. Examples of factors extent to which barriers perceived by general
that were identified include commitment to lead- practitioners for prescribing angiotensin-convert-
ership and cohesiveness of clinicians to a shared ing enzyme inhibitors in patients with chronic
mission or policy. More than half of the factors heart failure are related to underuse and under-
identified as having a large or extremely large dosing of these drugs, no significant relationships
effect were related to organizational capability could be found between the barriers perceived
for change.25 Therefore, interventions that aim and actual prescribing.29 Rather than focusing on
to enhance the organizational structure and pro- barriers, the PRECEDE-PROCEED model puts
mote a culture of collaboration, in addition to forth 3 levels of variables influencing adherence
targeting factors identified by the ICSI, may be to clinical guidelines: predisposing factors,
applicable to efforts for improving hand-wash- enabling factors, and reinforcing factors.30,31
ing practices.23,25 More recently, systems reengi- Predisposing factors include knowledge and atti-
neering has emerged as the latest stage of quality tudes of health care workers, enabling factors
improvement. In contrast to incremental cycles include capacity and resources, and reinforcing
of continuous quality improvement, these factors include opinions or behavior of others.
redesign efforts consist of radical redesign of
existing systems, often involving information Interventions to Improve Hand Hygiene
technology as a major component.26 A major
limitation of quality improvement strategies is A 2001 systematic review included 21 studies of
the lack of evidence to support their use. interventions aimed at increasing hand washing
Supportive data are largely based on intuition or in health care workers.3 Methodological prob-
are anecdotal,24 and this is recently supported by lems and multiple interventions make it difficult
the lack of sufficiently rigorous studies to be to interpret most of the studies. However, in 4
included in a systematic review of organiza- studies, performance feedback was assessed sep-
tional infrastructures to promote evidence-based arately as an intervention and demonstrated
nursing practice.27 promising results. Dubbert and colleagues con-
ducted a before-and-after trial in 18 intensive
From Theory to Practice care unit (ICU) nurses and found a 10% increase
over a 4-week period.17 Mayer and associates
It has been suggested that theoretical frameworks randomly assigned 1 of 2 ICUs to daily memos
for understanding barriers to changing hand on the previous day’s hand-washing perform-
hygiene may lead to practical interventions that ance. Hand washing rose from a baseline of 63%
attempt to alter individual, group, or organiza- to more than 90% in the experimental group
tional factors contributing to poor hand-hygiene compared with no increase in the comparison
behaviors.28 Identifying such barriers through group.32 Van de Mortel and colleagues con-
interviews, surveys, focus groups, Delphi meth- ducted a before-and-after study to assess the
ods, observation, auditing records, and data effect of weekly feedback conducted over 5
analysis has been suggested as a means to design months. They found increases in adherence up to
interventions that correspond to theoretically 90%: from baseline rates of 20% to 60%.33
identified behavioral deficits.23,28 Thus, it has Tibbals and co-workers showed results of hand-
been suggested that consideration be given to washing audits to 61 physicians in 1 ICU.34
strategies that target specific barriers.23 However, They found that hand-washing frequency
evidence exists to suggest that there the relation- increased from 32% to more than 60% and that
ship between perceived barriers and physician this was sustained for 2 months following the

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 Maskerine et al.

termination of feedback. Although problems erence articles, posters, and infection control
such as small study size, short duration, and lack practitioners’ discussion with staff. Alcohol gel
of appropriate control groups limit interpretation dispensers were installed and liquid soap made
of these studies, the results suggest a benefit available. Staff recorded hand hygiene on a stan-
from performance feedback. dardized form for episodes of patient contact
An additional study cited in this review was throughout the week. Feedback was delivered to
a large before-and-after study of a hand-hygiene all staff, not solely health care workers. An
campaign including the introduction of alcohol- audit-and-feedback intervention was performed
based hand disinfection, the use of wall posters, again 7 months later. A 40% increase in hand
and regular performance feedback to all health hygiene was observed after both intervention
care workers.35 The primary study outcome was time points. The number of MRSA infections
observed hand-washing compliance recorded by was significantly reduced (p < .05) in the year
infection control nurses twice yearly between following the intervention. Thus, both infection
1994 and 1997. Secondary outcomes included incidence and hand-hygiene performance indi-
nosocomial infection rates, number of methi- cated the success of this multiple intervention
cillin-resistant S. aureus (MRSA) infections in involving a feedback component.36 Another
patients, and the amount of alcohol-based hand study in a neonatal ICU examined not only the
rub distributed. Adherence to recommended frequency but also the quality of hand washing.
hand-hygiene practices improved progressively Hand-hygiene technique and duration were
from 48% in 1994 to 66% (p < .001). During the observed, and hand washing was recorded sepa-
same period, both overall health care-associated rately from alcohol-based hand-rub usage.
infection and MRSA transmission rates Infection surveillance was conducted over a 6-
decreased (both p < .05). Study limitations month period before and after the intervention
included a lack of randomization of health care strategy. The intervention applied in this setting
worker groups and the fact that the multimodal involved an ongoing audit of hand-hygiene com-
intervention was not partitioned so that the effect pliance coupled with an educational feedback
of individual components, such as audit and feed- component. The educational sessions were
back, could be analyzed separately.35 Despite developed after the first set of observations were
that the active ingredient of the intervention completed and were based on the problems iden-
remains unknown, the success of the interven- tified through observation as well as a question-
tion, maybe attributable to the needs assessment naire completed by staff. The intervention was
before the study’s initiation and the multifaceted conducted over a period of 1 year. Hand washing
intervention strategy, suggest that well-designed improved significantly (p < .001) after the inter-
interventions affect hand-hygiene compliance.23 vention, and the use of alcohol hand rub
Studies examining the effects of feedback increased. Hand-washing technique improved in
have been performed in various health care set- all aspects after the intervention. The duration of
tings. In one study, feedback intervention was hand washing did not change significantly after
used to improve hand hygiene in a plastic sur- the intervention, but the minimum recom-
gery unit.36 The study examined the effects of mended time for hand washing (10 seconds) was
audit and subsequent feedback, displayed to met both before and after the intervention.
staff in graphical form. Reductions in hospital- The infection rate in the health care setting
acquired MRSA infection were used as a marker decreased from 17.2 per 100 patient admissions
of improvement in hand washing between at 6 months before the intervention to 9.1 per
patient contacts. An educational intervention 100 patient admissions at 6 months after the
was incorporated in the study and involved ref- intervention. This study used audits and staff

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 Improving Hand Hygiene Among Health Care Workers

self-reported difficulties with hand hygiene to

devise educational seminars that provided feed- Lessons for Practice
back on hand hygiene to nurses and physicians.
The resulting improvement in hand hygiene and • Despite the evidence supporting the
decline in infection rate, observed over a 6- benefits of hand hygiene, compliance
month period, demonstrate the impact of consis- among health care professionals
tent feedback on hand-hygiene practices.37 remains low.

Limitations in Research Design • Performance feedback may be impor-

tant to improve hand hygiene.
As noted above, studies included in a systematic • A theoretical foundation is required to
review of interventions aimed at promoting hand explain the success or failure of change
washing were not of high methodological qual- interventions.
ity, having small sample sizes, lack of appropri-
ate follow-up, lack of or inadequately defined
control groups, and failure to conceal from sub-
jects that they were being observed.3 An impor-
tant issue is that many studies failed to use
hospital-acquired infection rate as a secondary tice and health care outcomes show a large range
outcome measure.3 A major limitation of the of effect size of this type of intervention, with
existing studies is the design. Most are limited relative risk differences of noncompliance with
by the before-after design. desired practice ranging from 0.09 (a 9%
absolute increase in noncompliance) to 0.71 (a
Suggestions for Future Research 71% decrease in noncompliance) (median 0.07,
interquartile range 0.02 to 0.11). The one factor
Based on this review of both the theories appli- that appeared to predict the effectiveness of audit
cable to improving adherence to hand hygiene and feedback across studies was baseline non-
and the state of the current literature, we believe compliance with recommended practice.
that an approach based on the health belief Therefore, because these are feasible to
model (eg, using posters to show negative conse- implement, they may be a worthwhile approach.
quences of not adhering to hand hygiene), rea- In terms of design, there is no doubt that a ran-
soned action (demonstrating benefit to the health domized controlled trial is the best. Therefore,
care worker and to the patient), and action theory we propose that a randomized controlled trial be
(giving rewards for the behavior) may be the done that combines health care worker education
most likely to lead to success. We would be with performance feedback and audit to assess
reluctant at this point to incorporate a total qual- the adherence to hand hygiene.
ity improvement approach given the lack of sup-
portive evidence. However, studies to assess the Summary
relationship between organizational culture,
health care worker interactions, and adherence to Lack of adherence to hand hygiene among
hand hygiene are highly relevant. Although the health care providers remains an important chal-
results are variable, current evidence suggests lenge. Barriers to hand hygiene must first be
that audit and feedback may be effective at identified and theory-based interventions devel-
changing behavior.38 In a recent systematic oped. Strategies such as performance feedback
review, audit and feedback on professional prac- may be important in improving hand hygiene,

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 Maskerine et al.

but rigorous randomized trials are needed to hygiene in health-care settings: Recommenda-
assess those strategies. tions of the Healthcare Infection Control
Practices Advisory Committee and the HIC-
References PAC/SHEA/APIC/IDSA Hand Hygiene Task
Force. Infect Control Hosp Epidemiol 2002;
23(12 suppl):S3–S40.
1. Emmerson AM, Enstone JE, Griffin M, Kelsey
MC, Smyth ET. The Second National 11. Blot SI, Vandewoude KH, Hoste EA,
Prevalence Survey of infection in hospitals: Colardyn FA. Outcome and attributable mor-
Overview of the results. J Hosp Infect 1996; tality in critically ill patients with bacteremia
32:175–190. involving methicillin-susceptible and methi-
cillin-resistant Staphylococcus aureus. Arch
2. Meers PD, Ayliffe GA, Emmerson AM, Leigh
Intern Med 2002; 162:2229–2235.
DA, Mayton-White RT, Mackintosh CA, et al.
Report on the national survey of infection in 12. Stelfox HT, Bates DW, Redelmeier DA. Safety
hospitals, 1980. J Hosp Infect 1981; 2:1–11. of patients isolated for infection control.
JAMA 2003; 290:1899–1905.
3. Naikoba S, Hayward A. The effectiveness of
interventions aimed at increasing handwashing 13. Conterno LO, Wey SB, Castelo A. Risk fac-
in healthcare workers: A systematic review. J tors for mortality in Staphylococcus aureus
Hosp Infect 2001; 47:173–180. bacteremia. Infect Control Hosp Epidemiol
1998; 19:32–37.
4. Boyce JM. New insights for improving hand
hygiene practices. Infect Control Hosp 14. Pittet D, Mourouga P, Perneger TV, Members
Epidemiol 2004; 25:187–188. of the Infection Control Program. Compliance
with handwashing in a teaching hospital. Ann
5. Semmelweis I. The LC etiology, concept, and
Intern Med 1999; 130:126–130.
prophylaxis of childbed fever. Translated by
Carter KC. Madison: University of Wisconsin 15. Larson E, Killien M. Factors influencing
Press, 1983. handwashing behavior of patient care person-
nel. Am J Infect Control 1982; 10:93–99.
6. Mortimer EA Jr, Lipsitz PJ, Wolinsky E,
Gonzaga AJ, Rammelkamp CH Jr. 16. Conly JM, Hill S, Ross J, Lertzman J, Louie
Transmission of staphylococci between new- TJ. Handwashing practices in an intensive
borns. Am J Dis Child 1962; 104:289–295. care unit: The effects of an educational pro-
gram and its relationship to infection rates. Am
7. Hand Washing Liaison Group. Hand washing:
J Infect Control 1989; 17:330–339.
A modest measure with big effects [editorial].
BMJ 1999; 318:686. 17. Dubbert PM, Dolce J, Richter W, Miller M,
Chapman SW. Increasing ICU staff handwash-
8. Teare L, Cookson B, Stone S. Hand hygiene:
ing: Effects of education and group feedback.
Use alcohol hand rubs between patients: They
Infect Control Hosp Epidemiol 1990;
reduce the transmission of infection [edito-
11:191–193.
rial]. BMJ 2001; 323:411–412.
18. Larson E, Kretzer EK. Compliance with hand-
9. Whitby M, McLaws ML, Berry G. Risk of
washing and barrier precautions. J Hosp Infect
death from methicillin-resistant
1995; 30(suppl):88–106.
Staphylococcus aureus bacteraemia: A meta-
analysis. Med J Aust 2001; 175:264–267. 19. Sproat LJ, Inglis TJJ. A multicentre survey of
hand hygiene practice in intensive care units. J
10. Boyce JM, Pittet D. Healthcare Infection
Hosp Infect 1994; 26:137—148.
Control Practices Advisory Committee (HIC-
PAC); Society for Healthcare Epidemiology of 20. Kretzer EK, Larson EL. Behavioral interven-
America (SHEA); Association for tions to improve infection control practices.
Professionals in Infection Control(APIC); and Am J Infect Control 1998; 26:245–253.
Infectious Diseases Society of America(IDSA) 21. Trunnell EP, White GL Jr. Using behavior
Hand Hygiene Task Force. Guideline for hand change theories to enhance hand hygiene

The Journal of Continuing Education in the Health Professions, Vol. 26 No. 3, Summer 2006 • DOI: 10.1002/chp

250
 Improving Hand Hygiene Among Health Care Workers

behavior. Educ Health (Abingdon) 2005; 31. Davis D, Evans M, Jadad A, Perrier L, Rath
18:80–84. D, Ryan D, et al. The case for knowledge
22. Walker AE, Grimshaw J, Johnston M, Pitts N, translation: Shortening the journey from evi-
Steen N, Eccles M. PRIME: PRocess model- dence to effect. BMJ 2003; 327:33–35.
ling in ImpleMEntation research: Selecting a 32. Mayer JA, Dubbert PM, Miller M, Burkett PA,
theoretical basis for interventions to change Chapman SW. Increasing handwashing in an
clinical practice. BMC Health Serv Res 2003; intensive care unit. Infect Control 1986:
3:22 [electronic publication]. 7:259–262.
23. Grol R, Grimshaw J. From best evidence to 33. van de Mortel T, Heyman L. Performance
best practice: Effective implementation of feedback increases the incidence of handwash-
change in patients’ care. Lancet 2003; ing by staff following patient contact in inten-
362:1225–1230. sive care. Aust Crit Care 1995; 8:8–13.
24. Shojania KG, Grimshaw JM. Evidence-based 34. Tibballs J. Teaching hospital medical staff to
quality improvement: The state of the science. handwash. Med J Aust 1996; 164:395–398.
Health Aff (Millwood) 2005; 24:138. 35. Pittet D, Huggonet S, Harbarth S, Mourouga
25. Solberg L. Guideline implementation: What P, Sauvan V, Touveneau S, et al. Effectiveness
the literature doesn’t tell us. J Qual Improv of a hospital-wide programme to improve
2000; 26(9):525–537. compliance with hand hygiene. Infection
Control Programme. Lancet 2000;
26. Locock L. Healthcare redesign: Meaning, ori-
356:1307–1312 [erratum published in Lancet
gins, and application. Qual Saf Health Care
2000; 356:2196].
2003; 12:53–57.
36. MacDonald A, Dinah F, MacKenzie D, Wilson
27. Foxcroft DR, Cole N. Organizational infra-
A. Performance feedback of hand hygiene,
structures to promote evidence based nursing
using alcohol gel as the skin decontaminant,
practice. Cochrane Database of Systematic
reduces the number of inpatients newly
Reviews 2006, Issue 1.
affected by MRSA and antibiotic costs. J
28. Grol R. Personal paper: Beliefs and evidence Hosp Infect 2004; 56:56–63.
in changing clinical practice. BMJ 1997;
37. Lam BC, Lee J, Lau YL. Hand hygiene prac-
315:418–421.
tices in a neonatal intensive care unit: A multi-
29. Kasje WN, Denig P, de Graeff P, Haaijer- modal intervention and impact on nosocomial
Ruskamp FM. Perceived barriers for treatment infection. Pediatrics 2004; 114(5):e565-e571
of chronic heart failure in general practice: [electronic publication].
Are they affecting performance? BMC Fam 38. Jamtvedt G, Young JM, Kristoffersen DT,
Pract 2005; 6:19 [electronic publication]. Thomson O’Brien MA, Oxman AD. Audit and
30. Green L, Kreuter M, Deeds S, et al. Health feedback: Effects on professional practice and
education planning: A diagnostic approach. health care outcomes. Cochrane Database of
Palo Alto, Calif: Mayfield Press, 1980. Systematic Reviews 2003, Issue 3.

The Journal of Continuing Education in the Health Professions, Vol. 26 No. 3, Summer 2006 • DOI: 10.1002/chp

251