Abstract
BackgroundThere is only limited understanding of why hand hygiene improvement strategies are successful or fail. It is therefore important to look inside the ‘black box’ of such strategies, to ascertain which components of a strategy work well or less well. This study examined which components of two hand hygiene improvement strategies were associated with increased nurses’ hand hygiene compliance.MethodsA process evaluation of a cluster randomised controlled trial was conducted in which part of the nursing wards of three hospitals in the Netherlands received a state-of-the-art strategy, including education, reminders, feedback, and optimising materials and facilities; another part received a team and leaders-directed strategy that included all elements of the state-of-the-art strategy, supplemented with activities aimed at the social and enhancing leadership. This process evaluation used four sets of measures: effects on nurses’ hand hygiene compliance, adherence to the improvement strategies, contextual factors, and nurses’ experiences with strategy components. Analyses of variance and multiple regression analyses were used to explore changes in nurses’ hand hygiene compliance and thereby better understand trial effects.ResultsBoth strategies were performed with good adherence to protocol. Two contextual factors were associated with changes in hand hygiene compliance: a hospital effect in long term (p < 0.05), and high hand hygiene baseline scores were associated with smaller effects (p < 0.01). In short term, changes in nurses’ hand hygiene compliance were positively correlated with experienced feedback about their hand hygiene performance (p < 0.05). In the long run, several items of the components ‘social influence’ (i.e., addressing each other on undesirable hand hygiene behaviour p < 0.01), and ‘leadership’ (i.e., ward manager holds team members accountable for hand hygiene performance p < 0.01) correlated positively with changes in nurses’ hand hygiene compliance.ConclusionThis study illustrates the use of a process evaluation to uncover mechanisms underlying change in hand hygiene improvement strategies. Our study results demonstrate the added value of specific aspects of social influence and leadership in hand hygiene improvement strategies, thus offering an interpretation of the trial effects.Trial registrationThe study is registered in ClinicalTrials.gov, dossier number: NCT00548015.
Highlights
There is only limited understanding of why hand hygiene improvement strategies are successful or fail
The findings of this study indicated the added value of strategy components aimed at social influence within teams and enhanced leadership of ward managers on nurses’ Hand hygiene (HH) behaviour
We found a significant relation between changes in HH compliance and differences in nurses’ experiences with social influence and leadership
Summary
There is only limited understanding of why hand hygiene improvement strategies are successful or fail. Strategies to improve adherence to practice guidelines are often multimodal and consist of a number of potentially effective components and related improvement activities [1,2,3] (See Table 1). All of these components might influence effectiveness both independently and interdependently. Despite the CONSORT guidelines [7], a detailed description of an improvement strategy — reporting on all components and corresponding activities — and how well the strategy was performed is often lacking This applies to information on contextual aspects such as the environment or setting, as well as factors that inhibited or promoted effectiveness [4,8]. It is necessary to combine the strength of an RCT with a well-designed process evaluation [9]
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