Applying thematic synthesis to interpretation and commentary in epidemiological studies: identifying what contributes to successful interventions to promote hand hygiene in patient care

Abstract

ObjectivesHand hygiene is considered the most important preventive measure for healthcare-associated infections, but adherence is suboptimal. We previously undertook a Cochrane Review that demonstrated that interventions to improve adherence are moderately effective. Impact varied between organisations and sites with the same intervention and implementation approaches. This study seeks to explore these differences.MethodsA thematic synthesis was applied to the original authors’ interpretation and commentary that offered explanations of how hand hygiene interventions exerted their effects and suggested reasons why success varied. The synthesis used a published Cochrane Review followed by three-stage synthesis.ResultsTwenty-one papers were reviewed: 11 randomised, 1 non-randomised and 9 interrupted time series studies. Thirteen descriptive themes were identified. They reflected a range of factors perceived to influence effectiveness. Descriptive themes were synthesised into three analytical themes: methodological explanations for failure or success (eg, Hawthorne effect) and two related themes that address issues with implementing hand hygiene interventions: successful implementation needs leadership and cooperation throughout the organisation (eg, visible managerial support) and understanding the context and aligning the intervention with it drives implementation (eg, embedding the intervention into wider patient safety initiatives).ConclusionsThe analytical themes help to explain the original authors’ perceptions of the degree to which interventions were effective and suggested new directions for research: exploring ways to avoid the Hawthorne effect; exploring the impact of components of multimodal interventions; the use of theoretical frameworks for behaviour change; potential to embed interventions into wider patient safety initiatives; adaptations to demonstrate sustainability; and the development of systematic approaches to implementation. Our findings corroborate studies exploring the success or failure of other clinical interventions: context and leadership are important.

The problem with ‘My Five Moments for Hand Hygiene’

“…The problem with… campaigns. 31 Health workers will need education and training to promote this new approach to hand hygiene.…”

“…36 Successful implementation requires leadership and cooperation throughout the organisation, understanding the context in which care takes place and embedding the intervention into wider patient safety initiatives. 31 Introducing new hand hygiene interventions fits well alongside the organisation-wide changes introduced to prevent the spread of SARS-CoV-2 and the part played by the infection prevention teams who spearheaded them. Public health messages throughout the pandemic have emphasised the importance of hand hygiene via the media, social media platforms and other advertising outlets.…”

Teaching health care students hand hygiene theory and skills: a systematic review

“…Despite the importance of the topic, ours appears to be the first systematic review to explore how health care students are taught about hand hygiene. This lack of attention is surprising given the emphasis placed on hand hygiene globally (World Health Organization 2009;Allegranzi et al 2013;Gould et al 2017), its contribution to the containment of antimicrobial resistance (Courtenay et al 2019) and the need to update clinicians regularly to ensure that knowledge, skills, and motivation are sustained (Drey et al 2020). There appears to be lack of appreciation of the risks associated with students' suboptimal hand hygiene performance and failure to appreciate that they are the future role models and custodians of good clinical practice.…”

Identifying interventions to improve hand hygiene compliance in the intensive care unit through co-design with stakeholders

“…This positive motivation could be achieved by encouraging senior staff members, particularly consultants and senior nursing staff, to act as role models for junior staff members 23 . However, it is important that in such interventions the role of different levels of leadership (e.g., senior clinical staff, management) and styles of leadership are clear if the intervention is to be effective 24 . Given the positive disposition of the stakeholders to these types of intervention, as well as the relative lack of research on this approach 15 , it is suggested that the efficacy of this approach should be examined in future research.…”