Using psychological theory to develop and test a tool for the implementation of evidence based practice : the case of hand hygiene practice

Background: The example of evidence based practice used for this research was hand hygiene. The aim of this research was: to develop and test a theory-based diagnostic instrument to accurately and prospectively assess the barriers and levers to hand hygiene practice to inform subsequent tailoring of implementation strategies. Study One: A qualitative study was carried out with health care practitioners (n=70) and recent hospital patients (n=25) to identify barriers and levers to hand hygiene in secondary care. A thematic analysis resulted in a list of 100 barriers and levers to hand hygiene. Study Two: A two round modified Delphi survey was administered to assess the fit of barriers and levers to hand hygiene to domains of the British Psychological Society theoretical framework. Expert participants were recruited from the fields of Infection Prevention and Control (n=l1) and Health Psychology (n=10). Consensus was achieved on the fit of 99 of 100 barriers and levers to the framework. Study Three: Studies one and two informed the construction of a questionnaire-style diagnostic instrument designed to identify barriers and levers to hand hygiene. Health care practitioners (a total of 470) from four NHS hospital trusts completed questionnaires in three rounds which allowed the instrument to be refined using psychometric testing principles. The result was a 35 item instrument demonstrating good levels of reliability and validity. Study Four: The instrument was used to carry out a feasibility study to assess whether theoretically based interventions could be tailored according to assessed barriers and levers to hand hygiene and to establish the potential effectiveness of such an approach. Barriers and levers to hand hygiene were assessed with 19 junior doctors in an NHS hospital trust. It was identified that such an approach was feasible and hand hygiene audits indicated the potential effectiveness of such an approach. Conclusion: The literature suggests that implementation strategies need to be theoretically based and tailored to assessed barriers and levers to hand hygiene. This study took a step forward in addressing these findings using the example of hand hygiene.