Nursing’s Role in Hand Hygiene Compliance

Nurses are central to the patient care experience. Not only do they interface with patients perhaps more than healthcare workers in any other role do, but they are also mediators between patients and physicians.

As a result, nurses are in a vital position to not only improve patient care, but also influence the behavior of staff and physicians to perform proper hand hygiene in order to prevent healthcare-associated infections (HAIs).

An unprecedented example of nurses playing a key role in changing not only their own behavior, but also the behavior of an entire organization, occurred at Spectrum Health, the largest not-for-profit healthcare system in western Michigan.

In 2009, Spectrum Health increased hand hygiene compliance from the national average of 60 percent to above 90 percent – in just 2 months.

Full Spectrum

According to the CDC, five percent of admitted patients acquire infections in the hospital, and nearly six percent of these patients die each year.1

Spectrum Health has sustained their impressive hand-hygiene compliance rate for the past 2 years, and is currently tracking at a rate of 96 percent and climbing.

This unprecedented compliance rate is the result of an initiative led by the system’s Infection Control and Prevention team, in partnership with researchers at VitalSmarts, a corporate training company.

The approach is based on the VitalSmarts Influencer Model.

This model was recognized as the “Change Management Approach of the Year” by MIT Sloan Management Review due to its multifaceted approach to changing organizational behavior.2

What’s more, the influence approach used at Spectrum Health is replicable. Leaders at Spectrum held a firm expectation that all staff-including clinical nurses-would comply with the culture change strategies outlined in the Influencer Model.

The six sources of influence described within the model provide nurses with a framework to implement the strategies in their own units to achieve similar hand hygiene compliance rates.

Clarify Measurable Results

Clinical nursing teams must first clarify their hand hygiene method.

Spectrum Health utilized the Michigan Hospital Association’s “Wash In Wash Out” (WIWO) expectation and established an initial goal of 90 percent compliance-they raised the goal to 95 percent within a few months.

Staff were expected to comply with CDC and WHO hand hygiene guidelines along with WIWO as the minimal accepted behavior and the measurement standard.

Find Vital Behaviors

The premise of the Influencer Model is that the solution to most problems is driven by a small handful of vital behaviors. If these behaviors are implemented, rapid sustained improvements will result. Below are the three vital behaviors that were adopted across Spectrum Health.

  • WIWO (Wash In Wash Out).
      Each person who enters and exits a patient room or patient space is expected to perform hand hygiene with soap and water or hand sanitizer.


  • Accountability
      . Hold one another accountable for hand hygiene. Each staff member is 100 percent accountable for his or her own hand hygiene behavior as well as 100 percent accountable for the behavior of coworkers.


  • Thank You.
      Whenever staff members are reminded to wash their hands (even if they have just washed), they respond by saying “thank you.”


Spectrum Health selected these three vital behaviors to simplify their large-scale change goals, establish a working framework, and remove any ambiguity associated with hand hygiene protocol.

Safety studies across myriad industries show persistent habits and checklists create more reliable and consistent performance than independent judgment and memory. To achieve the expectation of 100 percent compliance, behaviors need to become habits.

At Spectrum Health, holding others accountable provided the social influence to guarantee compliance-especially in hectic moments when nurses faced competing urgent priorities.

In addition to social influence, nurses’ fear of speaking up was decreased because they knew others would thank them for a verbal reminder rather than hold a grudge.

The key to Spectrum Health’s compliance rate is their understanding that every nurse must be invested in adopting the three vital behaviors. As a result, leaders recruited their nursing staff to become champions, mentors, and ambassadors of these behaviors.

In order to adopt the vital behaviors, leaders and nurses partnered to create and implement the following six-source strategy.

Use Six Sources of Influence

The Influencer Model organizes influence strategies into six sources that both motivate and enable people to change through personal, social, and structural forces. VitalSmarts researchers have found that when initiatives combine at least four sources of influence, they are 10 times more likely to succeed than those that utilize less than four sources.1

Source 1, Personal Motivation –

The goal of this source is to ignite nurses’ passion for hand hygiene-to help them see the three vital behaviors as “the right thing to do.” Following are a few of the interventions employed at Spectrum Health.

  • Link to a personal experience.
      Have a nurse share his or her personal experiences related to hospital-acquired infections. Encourage nurses to tell the story of a family member or patient who suffered from a hospital-acquired infection.


  • Link to an experience in the news.
      Ask other nurses to play detective. If they search the news, they’ll quickly find Norovirus and flu epidemics that illustrate the need for clean hands. Turn the search into a game with prizes for those who find the most impactful story.


  • Teach the skills to others.
      Encourage your peers to participate in community-education experiences. Have members of your unit volunteer in local schools to educate children about hand hygiene. Your unit will return with a renewed passion for hand hygiene.


  • Become your patient’s advocate.
      Your peers joined healthcare in large part because of their desire to help patients. Tap into that motivation and challenge them to take on the role of patient advocate.


  • Connect with purpose.
      Ask staff members and others who work in your area to sign a commitment board that asks them to uphold the three vital behaviors.


Source 2, Personal Ability –

Even the most motivated nurses are challenged by creating a routine behavior of WIWO along with their own personal judgments of other hand hygiene procedures. In addition, nurses need to become comfortable holding one another accountable.

  • Create scripts.
      Involve nurses in creating brief, nonjudgmental, and friendly scripts for reminding others to wash their hands, for responding to a reminder, and for reacting to resistance from a colleague.


  • Conduct role plays.
      Encourage nurses to practice the scripts until they feel comfortable speaking up to colleagues, doctors, and surgeons on their own. If the unit has achieved the support of one or more physicians, have a physician participate in a practice session. This will demonstrate that everyone needs reminders, regardless of his or her role or position.



Hand Hygiene

Watch a step-by-step handwashing video and download resources you can use in your facility.

Source 3, Social Motivation –

Social motivation strategies build positive peer pressure and create a shared value around the vital behaviors.

  • Obtain visible support from both formal and informal leaders. Identify the managers and physicians whose support would encourage your colleagues to get on board with hand hygiene. Meet with these formal and informal leaders and explain what you need from them.

  • Recruit physician supporters.
  • It is essential to have physician involvement in the initiative. Invite respected physicians to help champion the hand hygiene initiative, and then ask these physicians to recruit their colleagues.

  • Work through opinion leaders.
  • Opinion leaders are informal leaders who may or may not hold formal leadership positions, but who have authority because they are respected by their peers. Invite nurses who are opinion leaders to lead the way in practicing perfect hand hygiene and reminding others to do the same.

  • Showcase public commitments and permissions.
  • Create colorful and signed commitment posters and place them in public places for the staff, physicians, and even patients and family members to see.

  • Make it fun.
  • Confronting others can be stressful, so find ways to lower the pressure. For example, at Spectrum Health one physician called herself the Queen of Clean and wore a tiara. Her favorite line was, “Don’t make me take out my crown.”

Source 4, Social Ability –

The purpose of social ability is to create a team approach. Give your colleagues the support they need to wash up and remind others.

  • Have everyone remind everyone, regardless of role or position.

Staff members will on occasion forget to wash his or her hands. Therefore, as a staff agrees to greatly appreciate being reminded to wash by others.


  • Use opinion leaders to convert skeptics.

Anticipate that some nurses will object to being held accountable. Identify staff members and supportive physicians who have the credibility and skills needed to speak with these nurses and gain their support.


  • Engage partners outside your unit or clinic.

Encourage hand hygiene to be performed by anyone who enters your facility, for example, family members, visitors, and other ancillary staff.


Source 5, Structural Motivation –

Structural motivation creates incentives and rewards for acting on the vital behaviors. These rewards are most effective when used in moderation and in ways that enhance personal and social motivation.

  • Use individual rewards.
      Award small prizes that recognize people for washing up and for reminding others. Spectrum Health used stickers and gift certificates. Be quick to say “thank you” when others perform hand hygiene.


  • Celebrate success together.
      Celebrate improvements in compliance. Use a variety of activities including staff celebrations, or small prizes, such as movie tickets. A simple thank you note sent out electronically by leadership to all staff proved to be powerful for Spectrum Health.


Source 6, Structural Ability –

Structural ability includes changes in the physical environment to make hand hygiene more convenient, easier to remember, and easier to track.

  • Assessment
      . Conduct an assessment of the location of soap and hand sanitizer dispensers. Check your local fire code for their regulations on alcohol hand sanitizer. Collaborate with facilities staff to create a plan for cleaning, filling, and sustaining the function of the dispensers. If possible, mount dispensers just inside or just outside every patient room and meeting area.


  • Use reminder cards.
      Create pocket cards outlining the vital behaviors, and use them as reminders. At Spectrum Health, some nurses would slip a card to a physician to remind him or her to wash up.


  • Track performance.
      Set up a formal system for measuring and tracking hand hygiene performance. Display the data in a public area indicating ownership over the numbers. Make it a priority to review the data at staff meetings.


  • Use visual cues.
      Place signs and posters in the unit, and install screen savers on computers. Place hand sanitizer stations in key locations for use by staff, families, and other visitors.



Infection Control

Earn 3 Contact Hours on this issue of vital importance to all nurses.

Nurses as Leaders in Behavior Change

At Spectrum Health, the Infection Control & Prevention Team partnered with clinical nursing staff to lead the implementation of the Influencer model. Each individual nursing unit reviewed a list of the six-source interventions and selected ideas that would both motivate their staff and fit with the culture of their unit.

When replicating this strategy, it’s vital to incorporate an evaluation process into the improvement initiative. This evaluation process enables leaders to track actions and measure progress. Also anticipate that others will want to replicate impressive accomplishments. Identify ways to inform other units or the entire hospital of how to implement a hand hygiene initiative.


And remember, success attracts followers. Be prepared to tell a story of success and challenge others to make hand hygiene part of the culture within a hospital unit, a medical clinic, or wherever patient care is provided.

References for this article can be accessed here.

David Maxfield is vice president of research at VitalSmarts; David L. Dull is vice president of quality at Spectrum Health; Catherine Ostrowski is manager of the Infection Control team that led the hand hygiene initiative at Spectrum Health; and Bonnie Ozarow is director of corporate safety, accreditation, regulations and infection control and prevention at Spectrum Health.

About The Author