Healthcare-associated infections are ranked by the World Health Organization as one of the top 10 causes of hospital deaths worldwide . In Canada, they are the most common serious complication of hospitalization, affecting 10% of all patients in acute-care hospitals  and are the fourth leading cause of death . Healthcare-associated pathogens that can lead to infection are transmitted through direct and indirect contact, droplets, air, and the contaminated hands of healthcare workers (HCWs), the latter being the most common vehicles of transmission in most settings . Microorganisms are known to survive on hands for up to 60 minutes following contact with a patient or contaminated surface. Hand contamination increases with increasing time spend providing direct patient care, in the absence of appropriate hand hygiene .
Hand hygiene, defined as the act of washing one’s hands with soap and water or disinfecting them with an antiseptic agent, is the single most successful and cost-effective means of preventing healthcare-associated infections, as well as an effective means of preventing illness in the community that may lead to hospitalization [5–8]. Hand hygiene, before and after all patient or patient environment contact, before aseptic procedure, and/or after bodily fluid exposure, is recommended in all published infection control and public health guidelines and is considered the standard of care for all HCWs [5–10]. Yet many studies document that HCWs’ compliance with hand hygiene recommendations is consistently less than 50% [6, 11–15], with compliance among physicians routinely lower than that of other HCWs [16–19]. Locally, at the Ottawa Hospital (proposed for this study), physician hand hygiene compliance rates have increased significantly from 14–17% between 2004–6 to 65–69% in March 2011. In spite of this increase, however, physician compliance continues to lag behind that of most other occupational groups and is below the corporate goal of 80%.
Interventions to improve hand hygiene compliance
In 2010, Gould and colleagues  conducted an update of the 2007 Cochrane systematic review  on interventions to improve hand hygiene compliance in patient care. A total of four studies are included in the review: two from the original review and two from the update. Interventions tested included substitutions of products and different multifaceted campaigns that involved different levels of involvement by HCWs. Success in improving hand hygiene compliance was inconsistent across the four studies. The authors concluded that we lack sufficient research evidence to know which strategies improve hand hygiene compliance and that robust research is needed to further explore ‘the effectiveness of soundly designed and implemented interventions to increase hand hygiene compliance’ . Most recently, Fuller and colleagues conducted a cluster randomised controlled trial of a behaviourally designed feedback intervention in 60 hospital wards across England and Wales that were implementing a national hand-hygiene campaign . Findings revealed that the intervention, which coupled feedback to personalized action planning (compared to routine care), produced moderate and significant sustained improvements in hand-hygiene compliance . While this study indicates promising effects for the use of behaviourally designed feedback interventions to improve hand hygiene compliance, further implementation studies are required to determine the intervention’s effect in different settings and contexts.
Barriers and enablers to physician hand hygiene compliance
Reasons for low hand hygiene compliance by HCWs, and physicians specifically, are poorly understood. Studies investigating HCWs generally have reported a range of barriers, including environmental barriers (e.g., lack of access to sinks, difficulty of locating products, empty dispensers, dispensers and time constraints) and personal barriers (e.g., attitudinal beliefs, skin irritation from repeated hand washing) [23, 24]. Using a behavioural theory approach, Boscart and colleagues explored nurses’ perceived barriers and enablers to hand hygiene practice . Nurses focused on immediate consequences; for example, they identified their personal safety and their families’ safety as a core source of motivation to perform hand hygiene. They also described the importance of individual feedback and self-monitoring in order to increase their performance. With respect to barriers specific to physicians, research is limited. In a recent survey of attitudes towards hand hygiene, physicians reported ‘remembering to perform hand hygiene’ and ‘high workload or feeling too rushed’ as their top barriers to hand hygiene compliance . A second study, which surveyed a variety of HCWs including physicians, found environmental barriers to hand hygiene compliance to be dominant, including lack of soap, broken soap dispensers, and lack of paper towels . Educational gaps in infection control training among physicians also exist [17, 18, 28, 29]; however, strategies effective for improving infection control practices of other HCWs have had significantly less impact on physicians [30, 31]. Additional barriers that are specific to physicians that have been identified/postulated include: a perception among physicians that their compliance is much better than it actually is [32, 33]; the development of a more cavalier attitude towards infection control as clinical experience increases, with an associated drop in compliance rates [30, 34, 35]; the lack of positive role models among physicians who are part of a healthcare team [35–37]; and, the local (e.g., unit, hospital) culture of patient safety .
In summary, the barriers and enablers to physician hand hygiene compliance and effective interventions to improve their compliance have not been well explored. To our knowledge, no studies have specifically addressed physician hand hygiene compliance using a behavioural theory approach that encompasses both barrier and enabler assessment, followed by intervention design based on these assessments. Therefore, the aims of this study are, first, to identify the barriers and enablers to physician hand hygiene compliance, and then to develop and pilot a theory-based knowledge translation intervention to increase physicians’ compliance with best hand hygiene practice.
Our goal is to develop and evaluate a theory-based, knowledge translation intervention to provide practical guidance about how to improve physician hand hygiene compliance. However, the development and evaluation of complex interventions such as knowledge translation interventions raise specific methodological and conceptual challenges. We have therefore adopted the UK Medical Research Council Complex Interventions Framework (MRC Framework) [39
], which provides an iterative phased approach to the development and evaluation of complex interventions. The MRC framework suggests that the evaluation of complex interventions should follow a sequential approach, involving:
Phase 0: problem and contextual assessment, and development of the theoretical basis for an intervention;
Phase 1: definition of components of the intervention (using modeling or simulated techniques and qualitative methods);
Phase 2: exploratory studies to further develop the intervention and plan a definitive evaluative study (using a variety of methods);
Phase 3: definitive evaluative studies (using quantitative evaluative methods, predominantly randomized designs); and,
Phase 4: studies evaluating the sustainability of complex interventions.
Campbell and colleagues suggested that Phases 0–2 should be considered part of a larger iterative activity rather than as sequential studies, and highlighted that the insights gained during these early phases can make a valuable contribution to the development of the basic science of knowledge translation . Based upon current systematic reviews, it appears that many knowledge translation studies have involved definitive trials, with little evidence of preceding theoretical or modeling research . As a result, the interpretation of the current evidence base on the effectiveness and efficiency of different strategies is problematic because we lack a theoretical base for conceptualizing decision-making and behaviour change processes in different stakeholder groups. As a result, it is difficult to apply this evidence across a variety of health settings because we cannot identify which interventions are most likely, in particular settings, to be effective or efficient in improving quality. Further, we have little understanding of the causal mechanisms of different interventions. In this study, we will adopt an iterative approach (as suggested by Campbell and colleagues ) to the development and evaluation of a knowledge translation intervention to improve physician hand hygiene compliance.