University of Hertfordshire

From the same journal


  • Fuller Chris
  • Sarah Jane Besser
  • McAteer John
  • Savage Joanne
  • Sheldon Stone
  • Susan Michie
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Original languageEnglish
Pages (from-to)106-110
Number of pages5
JournalAmerican Journal of Infection Control
Early online date17 Dec 2013
Publication statusPublished - 1 Feb 2014



Insufficient use of behavioral theory to understand health care workers' (HCWs) hand hygiene compliance may result in suboptimal design of hand hygiene interventions and limit effectiveness. Previous studies examined HCWs' intended, rather than directly observed, compliance and/or focused on just 1 behavioral model. This study examined HCWs' explanations of noncompliance in "real time" (immediately after observation), using a behavioral theory framework, to inform future intervention design.


HCWs were directly observed and asked to explain episodes of noncompliance in "real-time." Explanations were recorded, coded into 12 behavioral domains, using the Theory Domains Framework, and subdivided into themes.


Over two-thirds of 207 recorded explanations were explained by 2 domains. These were "Memory/Attention/Decision Making" (87, 44%), subdivided into 3 themes (memory, loss of concentration, and distraction by interruptions), and "Knowledge" (55, 26%), with 2 themes relating to specific hand hygiene indications. No other domain accounted for more than 18 (9%) explanations.


An explanation of HCW's "real-time" explanations for noncompliance identified "Memory/Attention/Decision Making" and "Knowledge" as the 2 behavioral domains commonly linked to noncompliance. This suggests that hand hygiene interventions should target both automatic associative learning processes and conscious decision making, in addition to ensuring good knowledge. A theoretical framework to investigate HCW's "real-time" explanations of noncompliance provides a coherent way to design hand hygiene interventions.


This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence CC BY 3.0 Unported Copyright © 2014 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. Chris Fuller, Sarah Besser, Joanne Savage, John McAteer, Sheldon Stone, & Susan Michie, 'Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines', American Journa of Infection Control, Vol. 42 (2): 106-110, first published online 17 December 2013. The version of record is available online at doi:

ID: 10489547