Discrepancy between hygiene knowledge and behaviour – How we can overcome the barrier?


Every hospital has a set of hand hygiene compliance (HHC) guidelines as set out by the World Health Organisation (WHO)[1] with the objective of reducing hospital-acquired infections and antibiotic use. In this paper, we look at the healthcare workers’ (HCWs) knowledge of the hygiene guidelines gathered by questionnaires and compare these results with actual HHC measurements from an electronic hygiene system (the Sani Nudge system)[2].



A questionnaire was designed by hygiene nurses and physicians with relevant experience within the field to evaluate the HCWs’ knowledge of the hand hygiene guidelines. HCWs who have regular patient contact were identified as relevant responders for the questionnaire. Data was collected between November 2017 and January 2018 at a Danish University Hospital (Hospital A) by a researcher with a medical background. The respondents (HCWs) were randomly chosen and answered the questionnaire via an iPad.

Sani Nudge system and clinical testing

The Sani Nudge system is an electronic hand hygiene monitoring system which collects and records HHC. The HCWs in Hospital A had a Sani ID attached to their existing hospital ID badge and all sanitizing dispensers had a discreet Sani Sensor attached that detected if it was being used. The HCWs went about their daily routine as normal while the sensors and IDs continuously and accurately shared data on the location of HCWs and the use of alcohol dispensers. The data is anonymised and used to calculate HCWs’ compliance levels via algorithms based on the guidelines from WHO1. The clinical HHC data is from the same hospital that the questionnaire was performed.


In total, there were 175 HCWs who answered the questionnaire at Hospital A. The breakdown of personnel was as followed:

Role of personnelTotal: 175 participants
Cleaning assistant13%
Social and health assistant3%
Other (medical students)2%

According to the questionnaire, 57% of the HCWs recognised sanitizing using alcohol rub as the most effective way to kill bacteria on the hands (correct answer) while 25% thought that hand wash with water and soap was more effective and 18% thought the two methods were equally good (Figure 1). This indicates a general lack of knowledge that alcohol-based hand rubs are better than handwashing at killing bacteria even though this is well-documented.[3]


Figure 1: Results from the questionnaire at Hospital A

Interestingly, 70% of the HCWs answered that they know the rules of hand hygiene at the hospital and 29% answered “somewhat”, while only 1% answered that they did not know the guidelines. However, when looking into HHC for the study period among the HCWs using the Sani Nudge system, the overall compliance was 53% and only 11% of the HCWs in the Sani Nudge program had a high HHC (Figure 2). This shows a tendency of overestimating one’s own knowledge or that HCWs are struggling to translate complex hygiene guidelines into clinical practice.


Figure 2: Data collected through the Sani Nudge system at Hospital A

HHC in specific clinical situations

The HCWs were also asked whether they would sanitise in specific clinical situations which showed some interesting results. In regards to the medication rooms, the questionnaire showed that 85% of the HCWs knew that it was important to sanitize before handling medicine (Figure 3a) (only HCWs handling medicine were asked this question). However, the data collected by the Sani Nudge system revealed that only 61% of HCWs actually remembered to sanitise before handling medicine, showing a large discrepancy between knowledge and clinical behaviour (Figure 3b).  

Skærmbillede-2019-03-20-kl.-09.39.28-768x354Note: all answers were valid besides “Before going to the toilet” and “After handling medicine” highlighted in grey.
Figure 3a: Results from the questionnaire at Hospital A


Figure 3b: Compliance data collected with the Sani Nudge system at Hospital A

A similar picture was seen in the toilets where 90% of the HCWs thought it necessary to sanitise after going to the toilet. However, the Sani Nudge system showed an average HHC of only 72% which underlines that even though most HCWs know that sanitation is needed they do not always do it in clinical practice.  

Finally, in terms of HHC in patient rooms, most HCWs correctly answered that it was important to sanitize after touching the patient (96%) in order to reduce the spread of infection. In line with the findings above, the Sani Nudge system, however, showed a markedly lower HHC in practice (51%) and even fewer HCWs remembered to sanitise before patient contact (HHC of 37%).


This study illustrates the value of combining questionnaires with electronic HHC data. We found a clear discrepancy between HCWs’ knowledge of hand hygiene guidelines and their actual HHC behaviour. The most likely reason is that HCWs struggle to translate complex hygiene guidelines into clinical practice. This also means that if HCWs only take theoretical tests, such as e-learnings, they will still find it difficult to use the newly acquired knowledge in a clinical setting. In addition, HHC targets will not be met by intensifying hand hygiene training or introduction of hygiene campaigns. Most HCWs do know the theory but struggle to translate it into clinical practice. Thus, new learning methods need to be taken into consideration.

Based on several studies with the Sani Nudge system[4],[5] we have developed a 5-step improvement process that connects training with behaviour. Data from the Sani Nudge system is automatically analysed and provides relevant information regarding compliance behaviour which are being used to train the individual in overcoming clinical barriers and help them to comply with hygiene guidelines. The 5-step process is easy to implement and uses the data actively to support good hygiene behaviour and facilitate culture change. Several hospitals have been able to triple their HHC levels by introducing this process.

If your hospital, like others, are struggling with maintaining high HHC, then you will want to learn how the Sani Nudge electronic hand hygiene system can help you create a successful hand hygiene compliance program in your hospital. Book a demo meeting with us here to see how Sani Nudge works. 

[1] Sani nudge Blog. Available at https://knowledge.saninudge.com/

[2] Videnskab.dk Available at https://videnskab.dk/author/author/3174

[3] Centers for Disease Control and Prevention, 2002. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report

[4] World Health Organization, 2009. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge. 1st ed. Geneva: WHO Press.

[5] www.saninudge.com

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