title: Application of a theoretical framework for behavior change to hospital workers' real-time explanations for noncompliance with hand hygiene guidelines.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: UCL Research Department of Infection and Population Health, University College London, London, United Kingdom. Electronic address: christopher.fuller@ucl.ac.uk.
authors.forename: Chris
authors.initials: C
authors.lastname: Fuller
authors.affiliation: NIHR King's Patient Safety and Service Quality Research Centre, King's College London, London, United Kingdom.
authors.forename: Sarah
authors.initials: S
authors.lastname: Besser
authors.affiliation: UCL Research Department of Infection and Population Health, University College London, London, United Kingdom.
authors.forename: Joanne
authors.initials: J
authors.lastname: Savage
authors.affiliation: Scottish Collaboration for Public Health Research and Policy, Medical Research Council, University of Edinburgh, Edinburgh, Scotland, United Kingdom.
authors.forename: John
authors.initials: J
authors.lastname: McAteer
authors.affiliation: UCL Medical School, University College London, London, United Kingdom.
authors.forename: Sheldon
authors.initials: S
authors.lastname: Stone
authors.affiliation: Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom.
authors.forename: Susan
authors.initials: S
authors.lastname: Michie
mesh_terms: D001291:Attitude of Health Personnel; D001521:Behavior Therapy / Q000379:methods*; D003430:Cross-Sectional Studies; D019983:Guideline Adherence / Q000592:standards*; D006235:Hand Disinfection / Q000379:methods*; D063373:Hand Hygiene / Q000379:methods*; D006282:Health Personnel; D006761:Hospitals; D006801:Humans
keywords: Behavioral theory; Noncompliance