Patients’ capability, opportunity, motivation, and perception of inpatient hand hygiene

Published:October 29, 2019DOI:


      • Despite multiple hand hygiene resources in hospitals patient report minimal practice.
      • Majority of patients report hand hygiene products are for staff only not patients.
      • Patients perceive staff hand hygiene as more important than their own hand hygiene.
      • Patients report minimal use of sinks, wall hand sanitizer dispensers, towelettes.
      • Compared to home, patients report dissatisfaction with their inpatient hand hygiene.
      • Current inpatient hand hygiene practice and education strategies may be insufficient.


      Studies that examine the perceptions and behaviors of patients regarding patient hand hygiene rarely examine the viewpoint of patients about their hand hygiene behavior relative to current resources provided in the hospital.


      Voluntary interviews that employed a 16-item survey tool were used among patients (N = 107) in outpatient clinics at post-admission visits. The survey was created using the Behavior Change Wheel, Capability, Opportunity, Motivation Behavior model. Patients were asked whether they brought hand sanitizer to the hospital, used hospital resources to clean their hands, and their perspective on patient hand hygiene importance compared with hospital staff, as well as their satisfaction or lack of satisfaction with hand hygiene independence.


      Most of the participants (65, 60.7%) reported that prior to being admitted to the hospital, they were able to maintain cleaning their hands with little or no difficulty. During their admission, only 21 (19.6%) of the participants reported needing little or no assistance. More than one-half of the participants, 34 (31.8%) and 23 (21.5%), respectively, reported, mostly or completely agreeing that the hand hygiene of the health care staff was more important than their own. Close to one-half of the participants (50, 46.7%) reported not being satisfied at all with their ability to maintain their hand hygiene in the hospital, whereas only 10 (9.3%) were very satisfied with their ability to maintain hand hygiene.


      Findings from this study will enhance our understanding of how to incorporate inpatient hand hygiene into existing infection control programs in inpatient settings.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Infection Control
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cao J
        • Min L
        • Lansing B
        • Foxman B
        • Mody L
        Multidrug-resistant organisms on patients’ hands: a missed opportunity.
        JAMA Intern Med. 2016; 176: 705-706
        • Mody L
        • Washer L
        • Kaye KS
        • Gibson K
        • Saint S
        • Reyes K
        • et al.
        Multidrug-resistant organisms in hospitals: what is on patient hands and in their rooms?.
        Clin Infect Dis. 2019; 69: 1837-1844
        • Ardizzone LL
        • Smolowitz J
        • Kline N
        • Thom B
        • Larson EL
        Patient hand hygiene practices in surgical patients.
        Am J Infect Control. 2013; 41: 487-491
        • Sunkesula V
        • Knighton SC
        • Zabarsky TF
        • Kundrapu S
        • Higgins PA
        • Donskey CJ
        Four moments for patient hand hygiene: a patient-centered, provider-facilitated model to improve patient hand hygiene.
        Infect Control Hosp Epidemiol. 2015; 36: 986-989
        • Cheng VCC
        • Tai JW
        • Li WS
        • Chau PH
        • So SY
        • Wong LM
        • et al.
        Implementation of directly observed patient hand hygiene for hospitalized patients by hand hygiene ambassadors in Hong Kong.
        Am J Infect Control. 2016; 44: 621-624
        • Srigley JA
        • Furness CD
        • Gardam M
        Measurement of patient hand hygiene in multiorgan transplant units using a novel technology: an observational study.
        Infect Control Hosp Epidemiol. 2014; 35: 1336-1341
        • Knighton SC
        • McDowell C
        • Rai H
        • Higgins P
        • Burant C
        • Donskey CJ
        Feasibility: an important but neglected issue in patient hand hygiene.
        Am J Infect Control. 2017;
        • Tanner J
        • Mistry N
        Hand hygiene: product preference and compliance.
        Nurs Times. 2011; 107: 16-19
        • Rai H
        • Saldana C
        • Gonzalez-Orta M
        • Knighton SC
        • Cadnum J
        • Donskey CJ
        A pilot study to assess the impact of an educational patient hand hygiene intervention on acquisition of colonization with health care–associated pathogens.
        AmJ Infect Control. 2019; 47: 334-336
        • Fox C
        • Wavra T
        • Drake DA
        • Mulligan D
        • Bennett YP
        • Nelson C
        • et al.
        Use of a patient hand hygiene protocol to reduce hospital-acquired infections and improve nurses’ hand washing.
        Am J Crit Care. 2015; 24: 216-224
        • Barker A
        • Sethi A
        • Shulkin E
        • Caniza R
        • Zerbel S
        • Safdar N
        Patient hand hygiene at home predicts their hand hygiene practices in the hospital.
        Infect Control Hosp Epidemiol. 2014; 35: 585-588
        • Sunkesula VCK
        • Kundrapu S
        • Knighton S
        • Cadnum JL
        • Donskey CJ
        A randomized trial to determine the impact of an educational patient hand-hygiene intervention on contamination of hospitalized patient's hands with healthcare-associated pathogens.
        Infect Control Hosp Epidemiol. 2017; 38: 595-597
        • Li Y
        • Liu Y
        • Zeng L
        • Chen C
        • Mo D
        • Yuan S
        Knowledge and practice of hand hygiene among hospitalised patients in a tertiary general hospital in China and their attitudes: a cross-sectional survey.
        BMJ Open. 2019; 9e027736
      1. World Health Organization. WHO guidelines on hand hygiene in health care: first global patient safety challenge clean care is safer care. The WHO multimodal hand hygiene improvement strategy. Available from: Accessed January 18, 2018.

        • Michie S
        • Atkins L
        • West R
        The behaviour change wheel.
        A guide to designing interventions. 1st ed. Silverback Publishing, Sutton (Great Britain)2014: 1003-1010
        • Beck CT
        • Gable RK
        Ensuring content validity: an illustration of the process.
        J Nurs Meas. 2001; 9: 201-215
        • Nandrup-Bus I
        Mandatory handwashing in elementary schools reduces absenteeism due to infectious illness among pupils: a pilot intervention study.
        Am J Infect Control. 2009; 37: 820-826
        • Nandrup-Bus I
        Comparative studies of hand disinfection and handwashing procedures as tested by pupils in intervention programs.
        Am J Infec Control. 2011; 39: 450-455
        • Gerald LB
        • Gerald JK
        • Zhang B
        • McClure LA
        • Bailey WC
        • Harrington KF
        Can a school-based hand hygiene program reduce asthma exacerbations among elementary school children?.
        J Allergy Clin Immunol. 2012; 130: 1317-1324
        • Rai H
        • Knighton S
        • Zabarsky TF,
        • Donskey CJ
        Comparison of ethanol hand sanitizer versus moist towelette packets for mealtime patient hand hygiene.
        Am J Infect Control. 2017; 45: 1033-1034
        • Knighton SC
        • Dolansky M
        • Donskey C
        • Warner C
        • Rai H
        • Higgins PA
        Use of a verbal electronic audio reminder with a patient hand hygiene bundle to increase independent patient hand hygiene practices of older adults in an acute care setting.
        Am J Infect Control. 2018; 46: 610-616
        • Mody L
        Infection control issues in older adults.
        Clin Geriatr Med. 2007; 23: 499-514
        • O'Donnell M
        • Harris T
        • Horn T
        • Midamba B
        • Primes V
        • Sullivan N
        • et al.
        Sustained increase in resident meal time hand hygiene through an interdisciplinary intervention engaging long-term care facility residents and staff.
        Am J Infect Control. 2015; 43: 162-164