Improving compliance with hand hygiene practices has been a challenge in all healthcare facilities including the long-term care (LTC) setting. One of the most common modes of transmission of pathogens is via hands, and hand hygiene remains the most important infection prevention measure. In spite of efforts by the Centers for Disease Control and Prevention (CDC) and infection control professionals to educate about the importance of hand hygiene among healthcare workers and the public, we still see compliance at a low level.

In 2002, the CDC Advisory Committee published the Guideline for Hand Hygiene in Health-Care Settings. (1) The guideline promotes the use of alcohol-based hand sanitizers as a replacement or substitute for hand washing. Higher concentrations of 60% to 95% alcohol (vol/vol) are recommended because of their antibacterial activity. The adoption of the CDC Guideline by agencies including the Joint Commission and the Centers for Medicare & Medicaid Services has placed greater emphasis on infection prevention and control. Implementing and maintaining hand hygiene programs are included in these agencies compliance measures.   

Many LTC facilities have hand hygiene policies based on the 2002 CDC recommendations. Education and motivational activities focusing on the importance of hand hygiene, which includes hand washing and the use of alcohol-based hand sanitizers, have been implemented. A challenge to LTC is the placement of alcohol-based hand sanitizers so that they are safely used by healthcare workers and visitors, and available to residents as appropriate.

Dispensers have been mounted on procedure carts, in nursing stations, utility/work rooms and in locations where they can be safely accessed. Some healthcare workers have elected to carry individual hand sanitizers in their uniform pockets. Despite the availability of alcohol-based hand sanitizers and providing educational and motivational efforts to promote better hand hygiene, compliance with the simple technique of hand washing with soap and water or use of alcohol-based hand sanitizers continues to be sub-optimal.   

Challenges unique to long-term care 

LTC facilities serve a unique population and have environmental challenges that contribute to higher risks for infection transmission. Infection is the leading cause of morbidity and mortality, and infections account for 26%-50% of transfers from LTC to acute care hospitals. (2) Additionally, changes in acute care reimbursements have led to the transfer of acutely ill patients to LTC. This population may require continuous intensive acute care services because they are at a higher severity of illness, have multi-system complications (e.g., ventilator dependence) and may require complex medical regimens (e.g., multiple IV medications or TPN).

In addition to a high-risk population, residents may be infected or colonized with multiple drug-resistant organisms, and outbreaks of transmission of these pathogens and other infections (e.g., viral illnesses) are not uncommon. Private rooms for isolation are not always available, thus isolating and cohorting residents with infections present a logistical problem.       

Maintaining compliance and sustaining hand hygiene behavior after education, motivation, and feedback is problematic. Too often one sees short-term improvements in compliance. Individuals are taught at an early age to clean hands after using the toilet, before eating, and when soiled. These are learned behaviors that are inherent in us all. In a recent article by Whitby et al., facilitating hand washing compliance is not simply related to effort, but dependent on altering behavioral perceptions. (3)

The level of contamination or interventional task is too often how workers are motivated to clean hands. Healthcare workers are motivated to clean hands when performing tasks where there is a higher level of soiling, e.g., visible soil or known risk of contamination. But certain tasks such as touching the resident’s environment e.g., bedrails and clothing, and touching a resident’s skin or taking temperatures or blood pressures are not perceived as a motivating factor to clean hands.

The question to ask ourselves is, How can we change behavior? Is ongoing motivation, education and auditing or monitoring activities the answer? Is it through peer pressure? Should we involve residents and visitors in hand hygiene compliance monitoring? The answer to all of these questions is, Yes.

Changing behaviors 

Studies have shown that persons behave differently when they have knowledge that their hand washing compliance is being observed. (4) (5) (6) These studies demonstrated how the Hawthorne effect influenced alcohol-based hand sanitizer use and compliance was reduced when known observers were withdrawn. Therefore, is it desirable for organizations to have hand hygiene monitoring teams present on wards or departments on all shifts everyday in order to sustain compliance? This is ideal, but may not be practical to achieve.

Peer pressure and personal accountability involving residents and visitors may be the solution. In order for this to be successful, full support is required from top administration leaders, physician leaders, department and nursing unit management. Leadership should not only give verbal support for the activity but become actively involved with hand hygiene programs. This includes support of educational and motivational activities, financial support for quality hand hygiene products (cheapest is not always the best), involvement with hand hygiene team activities including education and monitoring, and stating clear expectations for accountability.

Outsider involvement

Should residents, families, visitors be involved in a hand hygiene program? Their involvement in a successful hand hygiene programs merits strong consideration. It is prudent that this group be informed regarding hand hygiene practices and prevention of infection transmission. Hand hygiene education should be a part of the admission assessment interview along with reinforcement through educational programs, brochures and signage. Critical to this education is proper technique for hand cleaning.

When possible, residents and their families should be encouraged to monitor hand washing compliance and ask their caregivers if they have cleaned their hands. Hand-washing sinks should be assessible. Even with bathrooms in most resident rooms, what is available for the resident who is bedridden and dependent on others for assistance? Is a hand sanitizer available at the bedside within reach for use? Is the bedridden resident provided a hand sanitizer with their meal trays? Is the resident offered hand hygiene before leaving his/her room for therapy, social activities and dining room?

There are many hand sanitizers in the form of rinses, gels, foams and wipes. Applying the correct amount of product to properly clean and disinfect hands is important in achieving good hand hygiene. Using an alcohol-based gel enhanced on a wipe for patient hand hygiene can provide better hand cleansing. An alcohol-based hand wipe is similar to a wash cloth-thus a familiar technique to all. With a wipe, the user creates the friction necessary for removal of soil. The soil and germs are wiped off, not rubbed in. Using an alcohol-based hand wipe, a caregiver, family member, or visitor can easily clean hands of a resident when he or she is not able or competent to clean their own hands.   

Aim high 

The goal of any hand hygiene program is perfection. Targeting 100% compliance with hand hygiene practices in not unrealistic. This requires involving all caregivers, residents, their families and visitors. Everyone should take personal accountability for their own safety and providing a safe environment for others. The challenge for everyone is changing behavior. Improved hand hygiene may be cost-saving because the costs for a successful and sustained program represent a small amount when compared with the financial impact associated with healthcare-associated infections. 

Jean Fleming, RN, MPM, CIC, is clinical director of infection prevention and education at Professional Disposables International Inc. (


(1) Boyce JM, Pittet, D, et. al.: “Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/ISDA Hand Hygiene Task Force.”  Infection Control and Epidemiology.  2002; 23 (12 suppl): S3-S40.

(2) Richards, Chesley.  “Infections in Residents of Long-Term Care Facilities:  An Agenda for Research Report of an Expert Panel”. JAGS  March 2002. Vol 20. No. 3: 570-576.

(3) Whitby M, McLaws M, Ross M.  Why healthcare workers don’t wash their hands: A behavioral explanation. Infection Control and Hospital Epidemiology 2006; 27: 484-491.

(4) Eckmanns T, Bessert J, Behnke M, Gastmeir P, Ruden H.  Compliance with antiseptic hand rub use in intensive care units:  The Hawthorne effect.  Infection Control and Hospital Epidemiology 2006; 27: 931-934.

(5) Bittner MJ, Rich EC, Turner PD, Arnold WH Jr.  Limited impact of sustained simple feedback based on soap and paper towel consumption on the frequency of hand washing in an adult intensive care unit.  Infection Control and Hospital Epidemiology 2002; 23: 120-126.

(6) Harbarth S, Pittet D, Grady L. et al.  Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance.  Pediatric Infectious Disease Journal 2002; 21: 120-126.