Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: A cluster randomised trial

BACKGROUND: Improving hand hygiene compliance is still a major challenge for most hospitals. Innovative approaches are needed. OBJECTIVE: We tested whether an innovative, theory based, team and leaders-directed strategy would be more effective in increasing hand hygiene compliance rates in nurses than a literature based state-of-the-art strategy. DESIGN AND SETTING: A cluster randomised controlled trial called HELPING HANDS was conducted in 67 nursing wards of three hospitals in the Netherlands. PARTICIPANTS: All affiliated nurses of the nursing wards. Wards were randomly assigned to either the team and leaders-directed strategy (30 wards) or the state-of-the-art strategy (37 wards). METHODS: The control arm received a state-of-the-art strategy including education, reminders, feedback and targeting adequate products and facilities. The experimental group received all elements of the state-of-the-art strategy supplemented with interventions based on social influence and leadership, comprising specific team and leaders-directed activities. Strategies were delivered during a period of six months. We monitored nurses' HH compliance during routine patient care before and directly after strategy delivery, as well as six months later. Secondary outcomes were compliance with each type of hand hygiene opportunity, the presence of jewellery and whether the nurses wore long-sleeved clothes. The effects were evaluated on an intention-to-treat basis by comparing the post-strategy hand hygiene compliance rates with the baseline rates. Multilevel analysis was applied to compensate for the clustered nature of the data using mixed linear modelling techniques. RESULTS: During the study, we observed 10,785 opportunities for appropriate hand hygiene in 2733 nurses. The compliance in the state-of-the-art group increased from 23% to 42% in the short term and to 46% in the long run. The hand hygiene compliance in the team and leaders-directed group improved from 20% to 53% in the short term and remained 53% in the long run. The difference between both strategies showed an Odds Ratio of 1.64 (95% CI 1.33-2.02) in favour of the team and leaders-directed strategy. CONCLUSIONS: Our results support the added value of social influence and enhanced leadership in hand hygiene improvement strategies. The methodology of the latter also seems promising for improving team performance with other patient safety issues. TRIAL REGISTRATION: ClinicalTrials.gov [NCT00548015]