婉若秋水 发表于 2012-6-19 22:52
“医生为什么不洗手”在办公室电脑上，明天找时间发上来。
Why Healthcare Workers Don’t Wash Their Hands: A Behavioral Explanation Michael Whitby, MD; Mary‐Louise McLaws, PhD; Michael W. Ross, PhD From the Centre for Healthcare Related Infection Surveillance and Prevention, Princess Alexandra Hospital, Brisbane (M.W.), and School of Public Health and Community Medicine, University of New South Wales, Sydney (M.‐L.M.), Australia; and World Health Organization Center for Health Promotion Research and Development, School of Public Health, University of Texas, Houston (M.W.R.). Address reprint requests to Michael Whitby, MD, Centre for Healthcare Related Infection Surveillance and Prevention, Princess Alexandra Hospital, Ipswich Road, Brisbane QLD 4102, Australia (whitbym@health.qld.gov.au).  Objective.To elucidate behavioral determinants of handwashing among nurses.  Design.Statistical modeling using the Theory of Planned Behavior and relevant components to handwashing behavior by nurses that were derived from focus‐group discussions and literature review.  Setting.The community and 3 tertiary care hospitals.  Participants.Children aged 9‐10 years, mothers, and nurses.  Results.Responses from 754 nurses were analyzed using backward linear regression for handwashing intention. We reasoned that handwashing results in 2 distinct behavioral practices—inherent handwashing and elective handwashing—with our model explaining 64% and 76%, respectively, of the variance in behavioral intention. Translation of community handwashing behavior to healthcare settings is the predominant driver of all handwashing, both inherent (weighted ) and elective (weighted ). Intended elective in‐hospital handwashing behavior is further significantly predicted by nurses’ beliefs in the benefits of the activity (weighted ), peer pressure of senior physicians (weighted ) and administrators (weighted ), and role modeling (weighted ) but only to a minimal extent by reduction in effort (weighted ). Inherent community behavior (weighted ), attitudes (weighted ), and peer behavior (weighted ) were strongly predictive of inherent handwashing intent. Conclusions.A small increase in handwashing adherence may be seen after implementing the use of alcoholic hand rubs, to decrease the effort required to wash hands. However, the facilitation of compliance is not simply related to effort but is highly dependent on altering behavioral perceptions. Thus, introduction of hand rub alone without an associated behavioral modification program is unlikely to induce a sustained increase in hand hygiene compliance. Although healthcare worker (HCW) compliance with handwashing guidelines is a cornerstone of ideal infection control practice, the rate of such compliance has proved to be abysmal. 1 A variety of interventions have been investigated with the intent of improving knowledge of and compliance with handwashing guidelines and then reinforcing these practices 2‐6; however, until recently, none have engendered evidence of sustained improvement during a protracted period. 7, 8In 2000, two groups published findings that provided hope to those concerned about improving handwashing practice. Pittet et al. 7 demonstrated that handwashing compliance among nurses at the University of Geneva hospitals increased to a maximum of 66% during a 48‐month period. This improvement was associated with concomitant decreases in healthcare‐acquired infection rates and cross‐transmission of methicillin‐resistant Staphylococcus aureus. The Geneva program was multilevel and multifactorial, with a number of interventions likely to affect HCW behavior. However, the particular focus of this program was the provision of an alcohol‐based hand rub designed to reduce the time taken and the inconvenience associated with handwashing. Subsequently, Larson et al. 8 described a significant increase in handwashing compliance that was sustained for a 14‐month period in a Washington, DC, teaching hospital. Their program attempted to induce organizational cultural change toward optimal hand hygiene, with senior administrative and clinical staff overtly supporting and promoting the handwashing program. After publication of the Geneva study, 7 commercially produced alcohol‐based hand rubs became widely marketed and introduced into hospitals, with the expectation that a sustained increase in compliance with handwashing guidelines would follow. The usefulness of such products has been reinforced on the basis of recommendations in internationally well‐respected guidelines. 9 Some reports of short‐term improvements in compliance that occurred after the introduction of alcohol‐based hand rubs, often recorded from overt observation, have been published. 10‐13Although the benefits of the interventions reported by Pittet et al. 7 and Larson et al. 8 are undoubted and the cost‐effectiveness of the programs has been justified, 14 we must now identify why these interventions were successful. Handwashing as a practice is a globally recognized phenomenon; however, the inability to motivate HCW compliance with handwashing guidelines suggests that handwashing behavior is complex. Human behavior is the result of multiple influences from our biological characteristics, environment, education, and culture. Although these influences (hereafter referred to as “components”) are usually interdependent, some have more force than others. Many theories have been developed to define the nature and relationship of multiple factors that affect a range of health‐related behaviors. Use of these theoretical behavior models has widely occurred in a number of areas of health education and health promotion, sometimes with considerable success. 15 The Theory of Planned Behavior (TPB) 16 is appropriately used when examining behaviors considered to be determined by a person’s intention. With regard to handwashing, the model is predicated on a person's acceptance that the immediate cause of handwashing is their antecedent intention to wash their hands. The intention to perform a given behavior is predicted directly, although to differing degrees, by 3 intermediate variables: attitude (a feeling that the behavior is associated with certain attributes or outcomes that may or may not be beneficial to the individual), subjective norms (a person’s perception of pressure from peers and other social groups), and perceived behavioral control (a person’s perception of the ease or difficulty in performing the behavior). These intermediate variables are predicted by the strength of the person's beliefs about the outcomes of the behavior, normative beliefs (which are based on a person's evaluation of the expectations of peers and other social groups), and control beliefs (which are based on a person's perception of their ability to overcome obstacles or to enhance resources that facilitate or obstruct their undertaking of the behavior). For each behavior, qualitative assessments, which usually take the form of focus‐group discussions, are initially used to best determine the content of each influencing component. This often means that predictive components described by other behavioral models can also be included in the final paradigm to best explain the behavior of interest. Our investigations focus on elucidating and determining the origin of the behavioral determinants of handwashing in nurses in the healthcare setting. |
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