Hand hygiene adherence and associated factors among nursing staff in long-term care facilities: A cross-sectional study
Article information
Abstract
Purpose
Despite the critical importance of hand hygiene (HH) in long-term care facilities, research on adherence and its determinants in these settings remains scarce. This study examined HH adherence and its associated factors among nursing staff in long-term care facilities.
Methods
This cross-sectional study surveyed 128 nursing staff members (registered nurses, n=78; nurse assistants, n=50). Data were collected from 35 long-term care facilities across South Korea. HH adherence was calculated from self-reported HH performances and opportunities based on the WHO Five Moments, and HH perception and infrastructure were assessed using adapted WHO-based instruments.
Results
The mean clinical experience of participants was 14.58±10.12 years. The HH adherence rate was 70.85%. The mean scores of HH perception and infrastructure were 73.41±11.65 out of 84 points and 32.42±5.18 out of 40 points, respectively. HH adherence was significantly associated with infrastructure (β=0.22, p=.042) and working in a specialized unit (β=0.22, p=.013).
Conclusion
This study identified HH infrastructure quality and working in specialized units as significant factors associated with HH adherence among nursing staff in long-term care facilities. These findings suggest that strengthening HH infrastructure and considering unit-level working conditions may contribute to improved adherence. Facility-wide multimodal strategies that combine infrastructure improvement with ongoing education are recommended to sustain HH practices in long-term care settings. Future research should examine system-level and organizational factors using multilevel designs to further elucidate determinants of HH adherence in these settings.
INTRODUCTION
Healthcare-associated infections (HAIs) represent a major threat to patient safety worldwide. Common HAIs include urinary tract infections, pneumonia, bloodstream infections, and skin and soft tissue infections. HAIs contribute to prolonged hospital stays, increased healthcare costs, and excess mortality [1]. The burden of HAIs is particularly pronounced in long-term care facilities (LTCFs), where communal living among frail older adults with multiple chronic conditions further amplifies LTCF residents’ risk of infection. LTCF residents are particularly vulnerable due to age-related immune senescence, polypharmacy, and decreased functional independence, which increase the likelihood of complications and mortality [2].
Hand hygiene (HH) is one of the most effective and economical methods of preventing HAIs. The World Health Organization (WHO) recommends HH at “Five Moments”: before touching a patient, after touching a patient, before clean/aseptic procedures, after body fluid exposure risk, and after touching patient surroundings [3]. Despite its recognized importance, HH adherence remains suboptimal across healthcare settings. In acute-care hospitals, median adherence rates have been reported at approximately 40%, with median non-intensive care unit ward adherence rates of 50%~60% and a mean intensive care unit adherence rate of 59.6% [4,5]. In LTCFs, reported adherence rates range from 17% to 58%, which are comparable to, or even lower than, those in acute-care settings [6,7].
The factors influencing HH adherence in LTCFs operate at multiple levels. HH perception refers to the nursing staff’s overall awareness of the importance of HH and the extent to which they prioritize it in routine care [8]. Healthcare workers with more positive HH perceptions tend to show better HH adherence [9]. At the environmental level, HH infrastructure, encompassing the availability and accessibility of sinks, alcohol-based hand rub, soap, disposable towels, and visual reminders, reduces practical barriers to adherence [3]. Beyond individual and environmental factors, work environment characteristics such as workload and staffing arrangements shape the time and opportunity available for HH practice [10]. These factors are likely interrelated, as suggested by the WHO multimodal HH improvement strategy, in which system change (infrastructure) and safety climate (perception) interact to influence adherence behavior [3].
In addition to these individual and environmental factors, occupational characteristics may further shape HH adherence [3,11]. In South Korea, registered nurses (RNs) and nurse assistants (NAs) are fundamentally distinct occupational groups, differing in educational attainment, licensure, and scope of practice. Under current regulations, LTCFs with 30 or more residents are required to employ at least one RN or NA per 25 residents [12], suggesting that both roles are considered comparable in meeting staffing requirements. This regulatory equivalence stands in contrast to their substantial differences in professional background, which may translate into differences in HH perception and adherence [3,11]. Whether HH adherence differs between these two groups in the LTCF context remains unexplored. Collectively, HH adherence in LTCFs is determined not only by individual awareness but also by the structural and occupational contexts in which care is delivered.
The existing literature on HH adherence, however, is limited primarily to studies conducted in acute-care settings, and evidence specific to LTCFs is scarce [13]. This gap is especially concerning given that South Korean LTCFs are not classified as medical institutions under national law [14]. As a result, they are subject to less stringent infection control requirements than hospitals, including the lack of concrete standards for HH facility installation [12,15]. This regulatory gap was starkly exposed during the coronavirus disease 2019 (COVID-19) pandemic, when clusters of infection in LTCFs resulted in disproportionately high mortality rates among residents, underscoring the distinctly vulnerable environment these settings present for HAI transmission [16,17]. Furthermore, the number of LTCFs in South Korea has increased rapidly, from 1,332 in 2008 to 4,525 in 2023 [18]. This growth further amplifies the need for evidence-based infection control strategies in these settings. Findings derived from acute-care hospitals may not be directly applicable to LTCFs, and the limited evidence specific to LTCFs, combined with less stringent regulatory requirements in South Korean LTCFs, highlight the need for further investigation.
Therefore, this cross-sectional study aimed to examine HH perception, infrastructure, and adherence among nursing staff—including both RNs and NAs—in South Korean LTCFs, and to identify factors associated with HH adherence in this population.
METHODS
Ethic statement: This study was approved by the Institutional Review Board (IRB) of Yonsei University (IRB No. Y-2020-0146). Informed consent was obtained from participants.
1. Study Design
A descriptive cross-sectional survey was conducted to examine the HH perception, infrastructure, and adherence among nursing staff in LTCFs. Factors associated with HH adherence were also identified. This study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.
2. Participants
Participants were recruited through a combination of purposive and snowball sampling. Facility lists were identified from the “2019 Older Adults Welfare Facilities Status” report published on the Ministry of Health and Welfare website [19]. Initially, facilities with larger staff numbers were prioritized for recruitment [19]. Recruitment was supplemented by snowball sampling through referrals from the initially sampled facilities. Eligible participants included RNs and NAs who had at least 3 months of work experience at their current facility and consented to participate after being informed of the study’s purpose. A minimum sample size of 127 was calculated using G*Power 3.1.9.2 (α=.05, effect size=.15, power=.80, 12 predictors). Accounting for a 20% dropout rate, the recruitment target was set at 153 participants.
3. Measurements
1) General Characteristics
Participants’ demographic and HH-related data, including sex, age, marital status, education level, occupation, work experience (total clinical experience, total LTCF experience, and current LTCF experience), work shift type, working unit, number of residents in charge, information regarding HH guidelines, and experience with HH education, were collected. Working units were categorized as either specialized units or general units. Specialized units provide 24-hour nursing care for residents with high medical needs, including indwelling catheter changes, wound management, and other complex nursing care procedures.
2) HH Adherence
Self-reported HH adherence was calculated by dividing the number of HH performances by the number of HH opportunities during the participants’ last shift. The HH adherence rate was calculated as:
Participants were asked to report how many HH opportunities occurred during their last shift, according to the five moments for HH, and how many times they performed HH. This approach is based on the WHO “Five Moments for Hand Hygiene” framework [3]. The HH adherence rate was then calculated using the formula above [20,21].
3) HH Perception
HH perception was assessed using the WHO HH Perception Survey, as translated and modified by Park and Kim [22] and adapted for LTCFs by Yoo [23]. The 12-item survey is rated on a 7-point Likert scale and measures HH improvement behavior (8 items), understanding the importance of HH adherence (3 items), and effort toward HH during patient care (1 item). Scores range from 12 to 84 points, with higher scores indicating better perception. The Korean version of the HH Perception Scale was validated by Oh [9], with a reported Cronbach’s α of .93. In the present study, Cronbach’s α was .89.
4) HH Infrastructure
HH infrastructure was measured using a modified version of the WHO Unit Infrastructure Survey, translated by the Korea Centers for Disease Control and Prevention [24]. The 10-item survey includes items assessing required HH resources and products (6 items) and activities aimed at improving HH (4 items). Items are rated on a 4-point Likert scale. Scores range from 10 to 40, with higher scores indicating better infrastructure. Cronbach’s α was .84, indicating good internal consistency.
4. Data Collection
Data were collected through an online survey between October 1 and November 30, 2020, among nursing staff in LTCFs across South Korea. The administrators of the selected LTCFs were contacted by telephone to explain the study’s purpose and obtain permission for data collection. Two recruitment methods were used: (1) obtaining phone numbers of interested nursing staff and sending them individual survey URLs, and (2) sending survey information and URLs to facility administrators. The online survey was conducted using the SurveyMonkey platform. A total of 140 nursing staff members from 35 LTCFs initiated the survey. After screening the responses for completeness, participants who discontinued the survey before completion were excluded, resulting in a final analytic sample of 128 participants (78 RNs and 50 NAs).
5. Data Analysis
Data were analyzed using SPSS version 25.0 (IBM Corp.). Descriptive statistics were used to summarize participants’ general characteristics and HH-related perception, infrastructure, and adherence. Differences in HH perception and adherence according to general and HH-related characteristics were analyzed using independent t-tests and one-way analysis of variance (ANOVA) with Bonferroni post-hoc tests. Relationships between variables were examined using Spearman’s correlation coefficient (rs).
To account for potential clustering of nursing staff within facilities, a linear mixed model with a random intercept for the facility was initially fitted. However, the variance component for the random intercept was estimated to be zero (intraclass correlation coefficient≈0), indicating negligible between-facility variance. This was likely attributable to the small and unbalanced sample sizes per facility, with many facilities having only one participating nursing staff member. Therefore, multiple linear regression analyses with individual-level predictors were used to identify the factors associated with HH adherence.
Variables to be included in the multiple regression model were selected according to the following criteria. Variables showing a significant association with HH adherence in the bivariate analyses were included. In addition, variables identified as relevant factors in previous studies were considered for inclusion regardless of their statistical significance in the bivariate analyses. Staff characteristics significantly associated with the key HH variables (perception and infrastructure) were also considered as covariates; when such characteristics were conceptually overlapping and significantly correlated with each other, only one was selected to maintain model parsimony. Multicollinearity among the variables included in the final model was assessed before interpreting the regression results. Statistical significance was set at p<.05.
RESULTS
1. Participants’ General and HH-Related Characteristics
A total of 128 nursing staff (78 RNs and 50 NAs) from 35 LTCFs participated in this study. Participants were predominantly women (98.4%), with a mean age of 52.27±9.65 years. The mean total clinical experience was 14.58±10.12 years, with the majority (66.4%) having more than 10 years of experience. Most participants (57.0%) worked in general units, while the remainder worked in specialized units. Each nursing staff member was responsible for an average of 55.75 residents. Descriptively, the mean number of residents per nursing staff member was lower in specialized units than in general units (39 vs. 68 residents).
Regarding HH characteristics, 93.8% of participants reported that their LTCFs followed HH guidelines, and 85.9% had received HH education within the preceding year. Participants could select multiple options for the types of HH education received. From the 169 total responses, in-person lectures were the most common (47.9%), followed by written materials (32.5%) and online education (19.5%) (Table 1).
General Characteristics and Hand Hygiene-Related Factors of Participants (N=128)
2. HH Perception, Infrastructure, and Adherence
The mean HH perception score was 73.41±11.65 (out of 84 points). The highest-rated item was “effort toward HH,” with an average score of 6.72 on a seven-point Likert scale.
HH infrastructure scored 32.42±5.18 out of 40, with required HH resources and products scoring 3.34±0.45 and activities for HH improvement scoring 3.10±0.74 on a four-point scale.
The overall self-reported HH adherence rate was 70.85%±25.77%. Adherence rates varied across the five moments for HH, with the highest adherence recorded after body fluid exposure risk (89.67%) and before clean/aseptic procedures (87.30%), and the lowest after touching a patient (67.95%) (Table 2).
Level of Hand Hygiene Perception, Adherence, and Infrastructure Among Nursing Staff (N=128)
3. Differences in HH Perception, and Adherence Rates According to Demographic and HH-Related Characteristics
HH perception differed significantly by age (F=4.76, p=.004), with post-hoc analysis revealing that participants under 40 years had significantly lower scores than those aged 60 years or older. Perception scores were also significantly higher among staff with 5 or more years of LTCF experience (F=5.14, p=.007). Additionally, staff in specialized units reported higher HH perception (t=2.07, p=.040) and HH adherence rates (t=2.54, p=.012) compared to those in general units (Table 3).
Hand Hygiene Adherence and Perception by Demographic Characteristics and Hand Hygiene-Related Factors of Participants (N=128)
4. Correlations Among HH Perception, Infrastructure, Adherence, and Demographic Variables
Significant but weak positive correlations were observed between HH adherence and HH perception (rs=.18, p=.045) and HH infrastructure (rs=.19, p=.028). A strong positive correlation was also observed between HH perception and infrastructure (rs=.59, p<.001), indicating a substantial relationship between the two. HH perception was positively correlated with both age (rs=.29, p<.001) and total LTCF work experience (rs=.22, p=.013) (Table 4).
Correlations Among Hand Hygiene Variables and Staff Characteristics (N=128)
5. Factors Associated With HH Adherence
Multiple regression analysis identified factors associated with HH adherence among nursing staff in LTCFs. Based on the criteria described in the Data Analysis section, working unit, occupation, age, HH perception, and HH infrastructure were included in the final regression model.
Multicollinearity was not a concern, with all variance inflation factors below 2 (range, 1.03~1.67), and the Durbin-Watson statistic of 2.34 indicated independence of residuals. The model explained 6.0% of the variance in HH adherence (adjusted R2=.06, F=2.58, p=.029). HH infrastructure (β=0.22, p=.042) and working in specialized units (β=0.22, p=.013) were significant factors associated with HH adherence. These findings indicate that better infrastructure and working in specialized units (compared to general units) are associated with higher HH adherence rates. Occupation was not significantly associated with HH adherence (β=0.07, p=.419) (Table 5).
Factors Associated With Hand Hygiene Adherence (N=128)
DISCUSSION
This study examined HH perception, infrastructure, and adherence among nursing staff in South Korean LTCFs. The self-reported adherence rate (70.85%) was below the 81% threshold that the WHO considers indicative of high-standard HH practice [25]. Previous studies that used direct observation of HH in LTCFs reported significantly low adherence rates of 17%~58% [6,7]. Compared to direct observations, self-reported measures tend to yield higher adherence rates, suggesting that actual HH adherence may be lower than the present findings suggest [26]. Additionally, since this study was conducted during the COVID-19 pandemic, increased awareness of infection control among nursing staff may have contributed to the elevated HH adherence rates.
The most concerning finding was the consistently low adherence rates for patient contact moments: after touching a patient (67.95%) and before touching a patient (68.22%). This pattern suggests that nursing staff may not fully recognize the importance of HH during routine resident interactions. These two moments are interconnected: a failure to perform HH after one patient contact directly increases the risk of contamination before the next. Targeted interventions focusing on these specific moments are therefore warranted.
This finding differs from those of Haenen et al. [6] and Liu et al. [27], which reported a higher adherence after patient contact. In contrast, the highest adherence rate in the present study was the “after body fluid exposure risk” moment (89.67%), suggesting that nursing staff distinguished between routine resident contact and situations involving exposure to body fluids. The high adherence rate for this moment is consistent with findings from other studies, suggesting that self-protection is a stronger motivator for HH among nursing staff than infection prevention during routine patient contact [7]. Therefore, educational strategies emphasizing personal protection benefits during routine care may be more effective than those focusing solely on patient safety.
Although 85.9% of participants had received HH education within the preceding year, their self-reported HH adherence rate (70.85%) fell short of the 81% WHO threshold [25]. This discrepancy suggests that current educational formats may increase awareness of HH but are insufficient to sustain behavioral change in clinical practice [28]. Simply providing periodic training may not be enough; an ongoing education framework that embeds HH into everyday workflows may be more effective.
This study identified HH infrastructure and working in a specialized unit as significant factors associated with HH adherence among nursing staff in South Korean LTCFs. HH infrastructure was significantly associated with HH adherence (β=0.22, p=.042). The physical accessibility of HH resources, including sinks, alcohol-based hand rub, soap, and disposable towels, reduces practical barriers to adherence at the point of care. Haenen et al. [6] similarly reported that approximately one-third of LTCF workers encountered problems with sink access and insufficient supplies.
A strong positive correlation was observed between HH perception and infrastructure (rs=.59, p<.001). Although perception was not an independent predictor in the regression model, its strong association with infrastructure may reflect a potential indirect relationship within a broader system-level context, consistent with the mutual amplification between “system change” and “safety culture” proposed by the WHO multimodal HH improvement strategy [3].
These findings support the need for interventions that simultaneously address infrastructure and perception. A cluster-randomized trial in Hong Kong LTCFs demonstrated that a WHO multimodal strategy combining infrastructure improvements with perception-enhancing interventions improved HH adherence from 27.0% to 60.6% and reduced respiratory outbreaks and MRSA infections [29]. Such approaches are particularly warranted in South Korean LTCFs, which currently lack concrete legal standards for HH facility installation—a regulatory gap not present in hospitals [12,15].
Working in a specialized unit was also significantly associated with higher HH adherence (β=0.22, p=.013). Two mechanisms may explain this finding. First, the high-risk nature of care in specialized units, including complex wound care, catheter management, and other invasive procedures, may heighten staff awareness of infection risk. Supporting this, specialized unit staff demonstrated significantly higher HH perception scores than general unit staff (t=2.07, p=.040). Second, specialized units operate under a mandated 6:1 bed-to-nursing staff ratio [30], resulting in lower resident-to-staff ratios compared to general units (39 vs. 68 residents per staff member). This reduced workload may provide staff with greater opportunity to perform HH, consistent with prior research linking increased workload to decreased HH adherence [6,9].
Contrary to expectations, occupation was not significantly associated with HH adherence (p=.419). While occupational differences in HH adherence have been reported in other healthcare settings [3,11], this finding may reflect the structural characteristics of South Korean LTCFs, where RNs and NAs operate under identical staffing standards and assume comparable caregiving responsibilities [12]. This shared work environment may attenuate occupation-based differences, suggesting that facility-wide approaches targeting shared infrastructure and working conditions are more appropriate than occupation-specific strategies.
1. Limitations
This study has several limitations. First, relying on self-reported HH adherence rather than direct observation may have led to an overestimation of actual adherence rates due to recall bias and social desirability bias. Future studies should employ direct observation methods to provide more accurate estimates of HH adherence. Second, the cross-sectional design limits causal inferences about the relationships between variables. Longitudinal studies tracking changes in adherence following infrastructure improvements would provide stronger causal evidence. Third, the limited explanatory power of the regression model (adjusted R2=.06) indicates that a substantial proportion of HH adherence variance was not explained by the variables included in this study. Future studies should incorporate broader organizational and facility-level factors using multilevel designs; findings from the current model should be interpreted accordingly.
2. Implications
These findings have direct implications for nursing practice and education in LTCF settings. Given that infrastructure emerged as a key modifiable factor associated with HH adherence, LTCFs should implement routine audits of HH resources and ensure their availability at the point of care. For example, placing alcohol-based hand rub dispensers at the bedside, ensuring a continuous supply of disposable towels, and displaying visual reminders in high-traffic care areas would serve as immediate and feasible interventions.
HH training programs should also incorporate moment-specific scenarios targeting routine resident contact, where adherence was lowest in this study. Such programs should explicitly emphasize personal infection risk during routine care, as self-protection appeared to be a stronger motivator than patient safety among LTCF nursing staff. Case-based education or simulation that highlights contamination risks between consecutive patient contacts may be particularly effective.
At the organizational level, facility-wide multimodal strategies that combine infrastructure improvement with ongoing education are recommended. Rather than focusing on occupation-specific interventions, integrated approaches that address shared working conditions across staff groups may be more effective and feasible in LTCF settings.
CONCLUSION
This study examined HH perception, infrastructure, and adherence among nursing staff in South Korean LTCFs, identifying infrastructure quality and working in specialized units as significant factors associated with HH adherence. These findings suggest that strengthening HH infrastructure and attending to unit-level working conditions may contribute to improved HH adherence. Facility-wide multimodal strategies that combine infrastructure improvement with ongoing education are recommended to sustain HH adherence in LTCFs.
Notes
Authors' contribution
Study conceptualization and methodology – EK and EC; Data collection and analysis – EK; Drafting and critical revision of the manuscript – EK, EC, GSK, and KHL; Supervision – EC, GSK, and KHL; All authors have read and agreed to the published version of the manuscript.
Conflict of interest
No existing or potential conflict of interest relevant to this article was reported.
Funding
This research was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (No. RS-2020-NR049581).
Data availability
Data cannot be shared owing to privacy and ethical restrictions.
Acknowledgements
This article is based on the first author’s master’s thesis from Yonsei University. English editing and language refinement for the entire manuscript were supported by the use of Claude AI (Anthropic) to improve clarity and readability. All content and revisions were thoroughly reviewed and approved by the authors.