Performance Feedback Intervention Research Articles

Developing a questionnaire to evaluate an automated audit & feedback intervention: a Rand-modified Delphi method

BackgroundAudit and feedback (A&F) is a widely used implementation strategy to evaluate and improve medical practice. The optimal design of an A&F system is uncertain and structured process evaluations are currently lacking. This study aimed to develop and validate a questionnaire to evaluate the use of automated A&F systems.MethodsBased on the Clinical Performance Feedback Intervention Theory (CP-FIT) and the REFLECT-52 (REassessing audit & Feedback interventions: a tooL for Evaluating Compliance with suggested besT practices) evaluation tool a questionnaire was designed for the purpose of evaluating automated A&F systems. A Rand-modified Delphi method was used to develop the process evaluation and obtain validation. Fourteen experts from different domains in primary care consented to participate and individually scored the questions on a 9-point Likert scale. Afterwards, the questions were discussed in a consensus meeting. After approval, the final questionnaire was compiled.ResultsA 34-question questionnaire composed of 57 items was developed and presented to the expert panel. The consensus meeting resulted in a selection of 31 questions, subdivided into 43 items. A final list of 30 questions consisting of 42 items was obtained.ConclusionA questionnaire consisting of 30 questions was drawn up for the assessment and improvement of automated A&F systems, based on CP-FIT and REFLECT-52 theory and approved by experts. Next steps will be piloting and implementation of the questionnaire.

A systematic review of performance feedback interventions targeting secondary teachers’ use of praise and reprimands

High rates of teacher praise are associated with positive student outcomes (Royer et al., 2019). Research shows secondary teachers deliver more reprimands than praise (e.g. Floress et al. 2022). Performance feedback (PF) is a strategy used to change teacher behaviors. However, it is unknown if PF targeting praise and reprimands for secondary teachers is an evidence-based practice. Although reviews on PF exist, none focus exclusively on secondary teachers. This review was to synthesize 14 PF intervention studies targeting praise and reprimands for secondary teachers. We evaluated PF studies to determine if PF is an evidence-based practice. Results indicate PF targeting praise and reprimands cannot yet be determined as an evidence-based practice for secondary teachers. Limitations, implications, and future directions are discussed.

Process and Implementation Elements of Measurement Feedback Systems: A Systematic Review.

Measurement feedback systems (MFS) can help guide treatment and improve clinical outcomes. Studies of MFS are heterogeneous both in execution and results, and the effects of MFS seem restricted by limited attention to process and implementation elements and by limited adoption by health professionals. The current systematic review mapped the use of process and implementation elements in MFS studies. An overview of therapists' use of and attitudes toward MFS is provided. Three-level meta-analyses were used to test theoretically informed process and implementation elements as moderators of the effects of MFS. Hypotheses and general propositions from Clinical Performance Feedback Intervention Theory (CP-FIT) were used to organize the elements of the studies and were used as moderator variables. Previous studies on MFS interventions have had a limited focus on implementation efforts and process elements that may increase the effects of MFS and their use among therapists. Efforts have sparsely been made to reduce barriers to MFS use, and several studies have reported limited engagement with MFS among therapists. Therapists' attitudes toward MFS, feedback, or standardized measures were heterogeneously reported, making data synthesis challenging. Identified process and implementation elements were not significantly associated with effect sizes in the studies and the results did not support the propositions of CP-FIT. The lack of statistically significant associations may be due to limited reporting of details about process and implementation aspects. More research designed to test hypotheses regarding process and implementation elements is needed to improve the use and effects of MFS. Future studies should aspire to report findings in a manner that allows for an understanding of the implementation process and therapists' adoption of these systems.

Implementing a Sodium-Glucose Cotransporter 2 Inhibitor Module With a Software Tool (Future Health Today): Qualitative Study.

Primary care plays a key role in the management of type 2 diabetes. Sodium-glucose cotransporter 2 (SGLT2) inhibitors have been demonstrated to reduce hospitalization and cardiac and renal complications. Tools that optimize management, including appropriate prescribing, are a priority for treating chronic diseases. Future Health Today (FHT) is software that facilitates clinical decision support and quality improvement. FHT applies algorithms to data stored in electronic medical records in general practice to identify patients who are at risk of a chronic disease or who have a chronic disease that may benefit from intensification of management. The platform continues to evolve because of rigorous evaluation, continuous improvement, and expansion of the conditions hosted on the platform. FHT currently displays recommendations for the identification and management of chronic kidney disease, cardiovascular disease, type 2 diabetes, and cancer risk. A new module will be introduced to FHT focusing on SGLT2 inhibitors in patients with type 2 diabetes who have chronic kidney diseases, cardiovascular diseases, or risk factors for cardiovascular disease. The study aims to explore the barriers and enablers to the implementation of an SGLT2 inhibitor module within the Future Health Today software. Clinic staff were recruited to participate in interviews on their experience in their use of a tool to improve prescribing behavior for SGLT2 inhibitors. Thematic analysis was guided by Clinical Performance Feedback Intervention Theory. In total, 16 interviews were completed. Identified enablers of use included workflow alignment, clinical appropriateness, and active delivery of the module. Key barriers to use were competing priorities, staff engagement, and knowledge of the clinical topic. There is a recognized benefit to the use of a clinical decision support tool to support type 2 diabetes management, but barriers were identified that impeded the usability and actionability of the module. Successful and effective implementation of this tool could support the optimization of patient management of type 2 diabetes in primary care.

Audit, Feedback, and Education to Improve Quality and Outcomes in Transurethral Resection and Single-Instillation Intravesical Chemotherapy for Nonmuscle Invasive Bladder Cancer Treatment: Protocol for a Multicenter International Observational Study With an Embedded Cluster Randomized Trial.

Nonmuscle invasive bladder cancer (NMIBC) accounts for 75% of bladder cancers. It is common and costly. Cost and detriment to patient outcomes and quality of life are driven by high recurrence rates and the need for regular invasive surveillance and repeat treatments. There is evidence that the quality of the initial surgical procedure (transurethral resection of bladder tumor [TURBT]) and administration of postoperative bladder chemotherapy significantly reduce cancer recurrence rates and improve outcomes (cancer progression and mortality). There is surgeon-reported evidence that TURBT practice varies significantly across surgeons and sites. There is limited evidence from clinical trials of intravesical chemotherapy that NMIBC recurrence rate varies significantly between sites and that this cannot be accounted for by differences in patient, tumor, or adjuvant treatment factors, suggesting that how the surgery is performed may be a reason for the variation. This study primarily aims to determine if feedback on and education about surgical quality indicators can improve performance and secondarily if this can reduce cancer recurrence rates. Planned secondary analyses aim to determine what surgeon, operative, perioperative, institutional, and patient factors are associated with better achievement of TURBT quality indicators and NMIBC recurrence rates. This is an observational, international, multicenter study with an embedded cluster randomized trial of audit, feedback, and education. Sites will be included if they perform TURBT for NMIBC. The study has four phases: (1) site registration and usual practice survey; (2) retrospective audit; (3) randomization to audit, feedback, and education intervention or to no intervention; and (4) prospective audit. Local and national ethical and institutional approvals or exemptions will be obtained at each participating site. The study has 4 coprimary outcomes, which are 4 evidence-based TURBT quality indicators: a surgical performance factor (detrusor muscle resection); an adjuvant treatment factor (intravesical chemotherapy administration); and 2 documentation factors (resection completeness and tumor features). A key secondary outcome is the early cancer recurrence rate. The intervention is a web-based surgical performance feedback dashboard with educational and practical resources for TURBT quality improvement. It will include anonymous site and surgeon-level peer comparison, a performance summary, and targets. The coprimary outcomes will be analyzed at the site level while recurrence rate will be analyzed at the patient level. The study was funded in October 2020 and began data collection in April 2021. As of January 2023, there were 220 hospitals participating and over 15,000 patient records. Projected data collection end date is June 30, 2023. This study aims to use a distributed collaborative model to deliver a site-level web-based performance feedback intervention to improve the quality of endoscopic bladder cancer surgery. The study is funded and projects to complete data collection in June 2023. ClinicalTrials.org NCT05154084; https://clinicaltrials.gov/ct2/show/NCT05154084. DERR1-10.2196/42254.

Physician Perceptions of Performance Feedback and Impact on Personal Well-Being: A Qualitative Exploration of Patient Satisfaction Feedback in Neurology.

To understand neurologists' experiences and perspectives on patient satisfaction feedback and its impact on personal well-being and behavior. From May to June 2021, the researchers conducted 19 semistructured interviews with neurologists from a large academic medical center. Clinical Performance Feedback Intervention Theory informed a combined inductive and deductive thematic analysis of the qualitative data, which focused on perceptions of current feedback practices, its impact on physician behavior, and recommendations for improvement. Participants tended to be female (n = 12/19, 63.2%), aged 30-39 (n = 8/19, 42.1%), white (n = 9/19, 47.4%), and were 10+ years into clinical practice (n = 18/19, 94.7%). Physicians were receptive to feedback overall, but perceptions varied by feedback type. Physicians preferred informal feedback (delivered unprompted directly by patients), given its tendency toward actionability. They disliked formal feedback (derived from anonymous surveys) due to low actionability, bias and validity issues, lack of contextual considerations, delivery through public reports, and links to financial incentives. Nearly all physicians reported formal feedback programs had the potential to negatively affect well-being and were not beneficial to their practice; a few reported adjusting their clinical practice to improve patient satisfaction performance. Five recommendations to improve patient satisfaction feedback programs emerged: Align on feedback intent, acknowledge survey limitations during program administration, increase actionability of feedback through specificity and control, support direct patient-physician feedback and problem resolution, and support empathetic integration of feedback. Understanding physician perceptions of current approaches to patient satisfaction feedback offers the opportunity to shape subsequent collection and distribution methods to improve physician performance and optimize professional fulfillment.

Optimization of a Quality Improvement Tool for Cancer Diagnosis in Primary Care: Qualitative Study.

BackgroundThe most common route to a diagnosis of cancer is through primary care. Delays in diagnosing cancer occur when an opportunity to make a timely diagnosis is missed and is evidenced by patients visiting the general practitioner (GP) on multiple occasions before referral to a specialist. Tools that minimize prolonged diagnostic intervals and reduce missed opportunities to investigate patients for cancer are therefore a priority.ObjectiveThis study aims to explore the usefulness and feasibility of a novel quality improvement (QI) tool in which algorithms flag abnormal test results that may be indicative of undiagnosed cancer. This study allows for the optimization of the cancer recommendations before testing the efficacy in a randomized controlled trial.MethodsGPs, practice nurses, practice managers, and consumers were recruited to participate in individual interviews or focus groups. Participants were purposively sampled as part of a pilot and feasibility study, in which primary care practices were receiving recommendations relating to the follow-up of abnormal test results for prostate-specific antigen, thrombocytosis, and iron-deficiency anemia. The Clinical Performance Feedback Intervention Theory (CP-FIT) was applied to the analysis using a thematic approach.ResultsA total of 17 interviews and 3 focus groups (n=18) were completed. Participant themes were mapped to CP-FIT across the constructs of context, recipient, and feedback variables. The key facilitators to use were alignment with workflow, recognized need, the perceived importance of the clinical topic, and the GPs’ perception that the recommendations were within their control. Barriers to use included competing priorities, usability and complexity of the recommendations, and knowledge of the clinical topic. There was consistency between consumer and practitioner perspectives, reporting language concerns associated with the word cancer, the need for more patient-facing resources, and time constraints of the consultation to address patients’ worries.ConclusionsThere was a recognized need for the QI tool to support the diagnosis of cancer in primary care, but barriers were identified that hindered the usability and actionability of the recommendations in practice. In response, the tool has been refined and is currently being evaluated as part of a randomized controlled trial. Successful and effective implementation of this QI tool could support the detection of patients at risk of undiagnosed cancer in primary care and assist in preventing unnecessary delays.

The Disaggregated Effects of Visual Performance Feedback on Teachers' Use of Behavior Specific-Praise and Reprimands.

Behavior-specific praise (BSP) is one of the simplest classroom management strategies to implement and considered an evidence-based practice. Unfortunately, teachers underuse BSP and deliver more reprimands to students in their classrooms. Secondary students receive the highest rates of reprimands and exclusionary discipline (i.e., office discipline referral [ODR], suspension, expulsion) with students of color receiving disproportionate rates compared to their White peers. Performance feedback is a commonly used strategy to change teacher practices however, little is known about the impact of performance feedback on the equitable delivery of BSP and reprimands to students by race and sex. The purpose of this multiple baseline design study was to examine the effects of a visual performance feedback (VPF) intervention with secondary teachers on their equitable delivery of BSP and reprimands and the collateral impacts on student outcomes. In the first phase of intervention, teachers received VPF on their total BSP and reprimands. In the second phase, teachers received disaggregated VPF on their rates of BSP and reprimands delivered to students by race and sex. Results indicate a functional relation between VPF and total BSP and an overall reduction in total reprimands. Mixed results were found between VPF and the equitable delivery of BSP and reprimands rates delivered to students by race and sex. Student outcomes indicated an increase in average class-wide academic engagement and no impact on ODRs as no teacher delivered a single ODR. Key findings, limitations, and future research are discussed.

Opportunities to improve the impact of two national clinical audit programmes: a theory-guided analysis

BackgroundAudit and feedback is widely used in healthcare improvement, with evidence of modest yet potentially important effects upon professional practice. There are approximately 60 national clinical audit programmes in the UK. These programmes often develop and adapt new ways of delivering feedback to optimise impacts on clinical practice. Two such programmes, the National Diabetes Audit (NDA) and the Trauma Audit Research Network (TARN), recently introduced changes to their delivery of feedback. We assessed the extent to which the design of these audit programmes and their recent changes were consistent with best practice according to the Clinical Performance Feedback Intervention Theory (CP-FIT). This comprehensive framework specifies how variables related to the feedback itself, the recipient, and the context operate via explanatory mechanisms to influence feedback success.MethodsWe interviewed 19 individuals with interests in audit and feedback, including researchers, audit managers, healthcare staff, and patient and public representatives. This range of expert perspectives enabled a detailed exploration of feedback from the audit programmes. We structured interviews around the CP-FIT feedback cycle and its component processes (e.g. Data collection and analysis, Interaction). Our rapid analytic approach explored the extent to which both audits applied features consistent with CP-FIT.ResultsChanges introduced by the audit programmes were consistent with CP-FIT. Specifically, the NDA’s increased frequency of feedback augmented existing strengths, such as automated processes (CP-FIT component: Data collection and analysis) and being a credible source of feedback (Acceptance). TARN’s new analytic tool allowed greater interactivity, enabling recipients to interrogate their data (Verification; Acceptance). We also identified scope for improvement in feedback cycles, such as targeting of feedback recipients (Interaction) and feedback complexity (Perception) for the NDA and specifying recommendations (Intention) and demonstrating impact (Clinical performance improvement) for TARN.ConclusionsThe changes made by the two audit programmes appear consistent with suggested best practice, making clinical improvement more likely. However, observed weaknesses in the feedback cycle may limit the benefits of these changes. Applying CP-FIT via a rapid analysis approach helps identify strengths and remediable weaknesses in the design of audit programmes that can be shared with them in a timely manner.

Systematic review and narrative synthesis of computerized audit and feedback systems in healthcare.

Objectives(1) Systematically review the literature on computerized audit and feedback (e-A&F) systems in healthcare. (2) Compare features of current systems against e-A&F best practices. (3) Generate hypotheses on how e-A&F systems may impact patient care and outcomes.MethodsWe searched MEDLINE (Ovid), EMBASE (Ovid), and CINAHL (Ebsco) databases to December 31, 2020. Two reviewers independently performed selection, extraction, and quality appraisal (Mixed Methods Appraisal Tool). System features were compared with 18 best practices derived from Clinical Performance Feedback Intervention Theory. We then used realist concepts to generate hypotheses on mechanisms of e-A&F impact. Results are reported in accordance with the PRISMA statement.ResultsOur search yielded 4301 unique articles. We included 88 studies evaluating 65 e-A&F systems, spanning a diverse range of clinical areas, including medical, surgical, general practice, etc. Systems adopted a median of 8 best practices (interquartile range 6–10), with 32 systems providing near real-time feedback data and 20 systems incorporating action planning. High-confidence hypotheses suggested that favorable e-A&F systems prompted specific actions, particularly enabled by timely and role-specific feedback (including patient lists and individual performance data) and embedded action plans, in order to improve system usage, care quality, and patient outcomes.Conclusionse-A&F systems continue to be developed for many clinical applications. Yet, several systems still lack basic features recommended by best practice, such as timely feedback and action planning. Systems should focus on actionability, by providing real-time data for feedback that is specific to user roles, with embedded action plans.Protocol RegistrationPROSPERO CRD42016048695.

Improving Paraeducator Mand Training for Students with Autism Spectrum Disorder through a Brief Performance Feedback Intervention

Improving Paraeducator Mand Training for Students with Autism Spectrum Disorder through a Brief Performance Feedback Intervention

Performance feedback on the quality of care in hospitals performing thrombectomy for ischemic stroke (PERFEQTOS): protocol of a stepped wedge cluster randomized trial

BackgroundAlthough the provision of performance feedback to healthcare professionals based on data from quality registries is common practice in many fields of medicine, observational studies of its effect on the quality of care have shown mixed results. The objective of this study is to evaluate the effect of performance feedback on the quality of care for acute ischemic stroke.MethodsPERFEQTOS is a stepped wedge cluster randomized trial in 13 hospitals in the Netherlands providing endovascular thrombectomy for ischemic stroke. The primary outcome is the hospital’s door-to-groin time. The study starts with a 6-month period in which none of the hospitals receives the performance feedback intervention. Subsequently, every 6 months, three or four hospitals are randomized to cross over from the control to the intervention conditions, until all hospitals receive the feedback intervention. The feedback intervention consists of a dashboard with quarterly reports on patient characteristics, structure, process, and outcome indicators related to patients with ischemic stroke treated with endovascular thrombectomy. Hospitals can compare their present performance with their own performance in the past and with other hospitals. The performance feedback is provided to local quality improvement teams in each hospital, who define their own targets on specific indicators and develop performance improvement plans. The impact of the performance feedback and improvement plans will be evaluated by comparing the primary outcome before and after the intervention.DiscussionThis study will provide evidence on the effectiveness of performance feedback to healthcare providers. The results will be actively disseminated through peer-reviewed journals, conference presentations, and various stakeholder engagement activities.Trial registrationNetherlands Trial Register NL9090. Registered on December 3, 2020

A Conceptual Replication of Targeted Professional Development to Increase Teachers’ Behavior-Specific Praise

Multitiered support for professional development (MTS-PD) is a framework for applying a three-tiered support system to teacher classroom management professional development through targeted training and coaching. In this study, we conceptually replicated two prior MTS-PD studies. Following a school-wide training on behavior-specific praise (BSP), we conducted screening observations to identify teachers in need of additional support. Four teachers were identified and agreed to participate in a multiple-baseline design study focused on providing a targeted PD on BSP followed by emailed and texted visual performance feedback. We observed a functional relation between performance feedback and teachers’ increased use of BSP among participants. Teacher acceptability surveys indicated the teachers approved of the performance feedback intervention and preferred receiving it via text due to ease of access. The results of this study provide further support for the MTS-PD framework along with meaningful considerations for future research. Supplemental data for this article is available online at https://doi.org/10.1080/2372966X.2020.1853486.

Generalization and Maintenance Effects of Writing Fluency Intervention Strategies for Elementary-Age Students: A Randomized Controlled Trial

This study examined whether 2 evidence-based intervention strategies resulted in maintenance and generalization of writing fluency gains. In this study, 115 third-grade students were randomly assigned to a performance feedback intervention condition, a goal setting intervention condition, or a control condition. Neither intervention strategy produced strong maintenance effects, and there were no statistically significant differences in students' generalization as a function of intervention strategy. Generalization was promoted by students' gender and by obtaining a level of fluency during the final intervention session.

Facilitating action planning within audit and feedback interventions: a mixed-methods process evaluation of an action implementation toolbox in intensive care

BackgroundAudit and feedback (A&F) is more effective if it facilitates action planning, but little is known about how best to do this. We developed an electronic A&F intervention with an action implementation toolbox to improve pain management in intensive care units (ICUs); the toolbox contained suggested actions for improvement. A head-to-head randomised trial demonstrated that the toolbox moderately increased the intervention’s effectiveness when compared with A&F only.ObjectiveTo understand the mechanisms through which A&F with action implementation toolbox facilitates action planning by ICUs to increase A&F effectiveness.MethodsWe extracted all individual actions from action plans developed by ICUs that received A&F with (n = 10) and without (n = 11) toolbox for 6 months and classified them using Clinical Performance Feedback Intervention Theory. We held semi-structured interviews with participants during the trial. We compared the number and type of planned and completed actions between study groups and explored barriers and facilitators to effective action planning.ResultsICUs with toolbox planned more actions directly aimed at improving practice (p = 0.037) and targeted a wider range of practice determinants compared to ICUs without toolbox. ICUs with toolbox also completed more actions during the study period, but not significantly (p = 0.142). ICUs without toolbox reported more difficulties in identifying what actions they could take. Regardless of the toolbox, all ICUs still experienced barriers relating to the feedback (low controllability, accuracy) and organisational context (competing priorities, resources, cost).ConclusionsThe toolbox helped health professionals to broaden their mindset about actions they could take to change clinical practice. Without the toolbox, professionals tended to focus more on feedback verification and exploring solutions without developing intentions for actual change. All feedback recipients experienced organisational barriers that inhibited eventual completion of actions.Trial registrationClinicalTrials.gov, NCT02922101. Registered on 26 September 2016.

Intervention Enhancing Effects of Acceptance and Commitment Training on Performance Feedback for Direct Support Professional Work Performance, Stress, and Job Satisfaction.

Direct service professionals (DSPs) provide the majority of treatment to individuals with developmental disabilities in community and residential settings; however, their ability to implement high-quality care is often limited by workplace factors and stress. The present study examined the effect of a verbal and written performance feedback intervention and the addition of an acceptance and commitment therapy (ACT)-based training program on the frequency and technical competence of active treatment provided by DSPs using a multiple-baseline design across 5 participants. Each participant demonstrated an increase in active treatment and technical performance following the implementation of both feedback-only and feedback plus ACT training interventions. Self-reported levels of psychological flexibility, workplace stress, and job satisfaction remained relatively stable for all participants from baseline to intervention despite the increased performance of the DSPs. Implications of the inclusion of an ACT-based training program with traditional behavior-analytic workplace interventions are discussed.

Effects of Performance Feedback on the Writing Fluency of Students with Oppositional Defiant Disorder

Students with oppositional defiant disorder (ODD) and other emotional and behavioral disorders (EBD) often have significant academic needs, particularly in the area of writing. There is currently a need to identify intervention strategies that can be efficiently implemented in the school setting to improve the writing fluency outcomes of students from this population. Performance feedback has been successfully used to improve typically developing students’ writing fluency; however, its isolated effects for students with ODD are unknown. The purpose of this study was to examine whether the writing fluency gains of an evidence-based performance feedback intervention could be replicated with a sample of students with ODD. Results of a multiple baseline design failed to demonstrate three replications supporting its effectiveness. Implications for practice are discussed in the context of the unique behavioral needs of students with ODD.

Call for papers. Special Issue: Innovation in Performance Management and Feedback Interventions

Call for papers. Special Issue: Innovation in Performance Management and Feedback Interventions

The contribution of mastery experiences, performance feedback, and task effort to elementary-aged students' self-efficacy in writing.

Although intervention procedures exist for improving elementary-aged students' writing fluency skills, less is known about how their writing self-efficacy develops upon participating in these procedures. In this study, 117 second grade students participated in an evidence-based performance feedback writing intervention. Students reported higher levels of self-efficacy in their writing abilities after participating in the intervention than they did at baseline. Although their experiences with task mastery and positive feedback did not impact their writing self-efficacy, the effort they put forth during the intervention was a significant predictor. These results may provide initial guidance for the development of students' self-efficacy in the context of school-based interventions, and they have specific implications for how the performance feedback intervention procedures may be refined to more systematically target students' task effort in future research. (PsycINFO Database Record

Hand hygiene compliance and behavioural determinants in a paediatric intensive care unit: An observational study

BackgroundHand hygiene is considered the single most effective means of reducing healthcare-associated infections, but improving and sustaining hand hygiene compliance remains a great challenge. ObjectivesTo compare hand hygiene compliance before and after interventions to promote adherence in a paediatric intensive care unit (PICU) and to identify predictors of intention to perform the behaviour “hand hygiene during patient care in the PICU”. MethodsA before and after study was conducted in three phases. Based on the World Health Organization guideline for hand hygiene compliance monitoring, 1261 hand hygiene opportunities were directly observed during routine patient care by two observers simultaneously, in a nine-bed PICU in Brazil, before and after infrastructure and educational interventions. To identify predictors of healthcare professionals' intention to perform the behaviour hand hygiene during patient care, a data collection instrument was designed based on the Theory of Planned Behaviour. Statistical analyses were undertaken using Chi-square test or the Fisher's exact test and regression analysis. A significance level of 5% (p < 0.05) was applied to all analyses. ResultsThe hand hygiene compliance rate increased significantly from 27.3% in the “pre-intervention phase” to 33.1% in “phase 1—post-intervention,” to 37.0% in “phase 2—post-intervention” (p = .010). Perceived social pressure (p = .026) was a determinant factor of intention to perform the behaviour. ConclusionsHand hygiene compliance raised significantly after infrastructure, educational, and performance feedback interventions. However, despite the significant effect of the implemented interventions, the overall hand hygiene compliance rate was low. Perceived social pressure characterised a determinant factor of intention to perform the behaviour “hand hygiene during patient care in the PICU”, reinforcing the need for behaviour determinants analysis when designing promotional interventions.