Received: 9 May 2018 Revised: 20 November 2018 Accepted: 24 November 2018

DOI: 10.1111/ijn.12720

ORIGINAL RESEARCH PAPER

High nursing workload is a main associated factor of poor hand

hygiene adherence in Beijing, China: An observational study
Shan Zhang BN, Postgraduate Student1 | Xiangping Kong RN, Lecturer2 |

Karen V. Lamb DNP, RN, Associate Professor3 |

Ying Wu PhD, RN, ACNP, ANP, FAAN, Professor1

1
School of Nursing, Capital Medical
University, Beijing, China
2
Teaching Administration, Beijing Chaoyang
Hospital, Beijing, China
3
College of Nursing, Rush University, Chicago,
Illinois, USA
Correspondence
Ying Wu, School of Nursing, Capital Medical
University, 10 You‐an‐men Wai Xi‐tou‐tiao,
Feng‐tai District, Beijing 100069, China.
Email: helenywu@vip.163.com
Abstract
Aim: The aim of the study was to explore the impact of nurse workloads on
adherence to hand hygiene.
Background: Adherence to hand hygiene and nursing workloads have been linked
to quality of patient care. Therefore, it was important to understand the relationship
to safe patient care.
Design: This cross‐sectional study was performed from January 2016 to June 2016.
Methods: Workloads and adherence to hand hygiene for nurses on 3‐day shifts
in a tertiary hospital were investigated in 2016. Actual hours worked per shift
were timed using a stopwatch to assess nursing workloads. Descriptive and
inferential statistics and multiple variable regression analysis were used to analyse
the data.
Results: Sixty‐four nurses from four wards were observed. The average adherence
rate of hand hygiene was 26.6% and the average nursing workload per shift was
6.7 hours. Multiple regression revealed that nursing workload was negatively related
to adherence rate of hand hygiene.
Conclusion: Nurses in this study that had a low rate of adherence with hand
hygiene frequently had high workloads. Adherence to hand hygiene was indepen-
dently associated with actual hours worked per shift.

KEY W ORDS

adherence, hand hygiene, hospital‐acquired infections, nurses, nursing workload

S U M M A R Y ST A T E M E N T • High workloads are a common problem worldwide because of the

shortage of nurses.
What is already known about this topic?
What this paper adds?
• Adherence to proper hand hygiene by nurses is one of the most
effective and efficient ways to prevent the spread of hospital‐ • Nurses on surgical wards worked long hours.

acquired infections and the dissemination of multi‐antimicrobial • Adherence to hand hygiene was negatively related with nursing
resistance. workloads.
• Adherence to hand hygiene among clinical nurses has been contin- • Nurses prefer hand washing to alcohol‐based hand rub for hand
ually substandard and nurses' high workload is their most common hygiene.
self‐reported reason for nonadherence. The implications of this paper:

Int J Nurs Pract. 2019;e12720. wileyonlinelibrary.com/journal/ijn © 2019 John Wiley & Sons Australia, Ltd 1 of 8
https://doi.org/10.1111/ijn.12720
2 of 8
• In the general ward, high workloads pose barriers to adherence to
hand hygiene, and any improvement efforts should be considered
in this context.
• In general, increased numbers of patients are to be cared for lead to
more opportunities for hand hygiene, but this heavy workload con-
tributes to a lack of adequate time to perform proper hand hygiene,
with a resulting decrease in adherence to hand hygiene.
• This study highlights the need for improvement programmes focus-
ing on the quality and adherence rates for proper hand hygiene.
• Measuring adherence rates with hand hygiene and nursing work-
loads are helpful for both proper allocation of nursing resources
and enhancement of patient safety.
1 | I N T RO D U CT I O N
Hospital‐acquired infections (HAIs) are an ongoing global problem,
which are mainly caused by multidrug‐resistant (MDR) Gram‐negative
organisms, with a prevalence of 5% to 15% (Giammanco, Cala,
Fasciana, & Dowzicky, 2017; Magill et al., 2014) in hospitalized
patients. HAIs present a universal challenge for all health‐care facilities
since more than 1.4 million patients in both developed and developing
countries are estimated to be affected at any given time (Magill et al.,
2014). In hospital settings, HAIs are major causes of longer stays, long‐
term disability, higher treatments costs, and increased antimicrobial
drug resistance and have consistently been linked to increased mor-
bidity and mortality (Erasmus et al., 2011; Lapão, Marques, &
Gregório, 2016). Numerous studies provide evidence that contamina-
tion on health‐care workers' (HCWs) hands are the most important
source of transmission of pathogens in hospitals, and such contamina-
tion occurs from touching patients or the objects in the environment
surrounding them (Farhoudi et al., 2016; Teter, Millin, & Bissell, 2015).
Hand hygiene is regarded as an extremely effective and efficient
precaution for minimizing cross‐transmission of MDR microorganisms
and reducing the incidence of HAIs (Erasmus et al., 2011; Huis et al.,
2012; Huis et al., 2013; Rosetti & Tronchin, 2015; Srigley, Furness,
Baker, & Gardam, 2014). Hand washing and alcohol‐based hand rub
(ABHR) are the most frequently used hand hygiene strategies. For
many decades, hand washing with soap and water was regarded as
the best method to prevent HAIs in health care (Kampf, 2003). In
2002, the Centers for Disease Control (CDC) released a new edition
of hand hygiene guidelines and initially endorsed ABHR in the guide-
line to deal with the hand contamination issue of HCWs (Boyce &
Pittet, 2002). Regardless of the strategy, both are intended to reduce
transmission of microorganisms on the hands. Despite World Health
Organization (WHO) and CDC recommendations, adherence to hand
hygiene among clinical nurses is often suboptimal (Azim, Juergens, &
McLaws, 2016; Erasmus, Daha, & Brug, 2010; Lee et al., 2014), rang-
ing from 5.0% to 81.0%, with an average adherence at approximately
40.0% (WHO, 2009a). A recent published study showed that the aver-
age adherence to hand hygiene of nurses was 58.1% (Shabot et al.,
2016). In China, the adherence to hand hygiene ranged from 49.1%
to 72.2% (Sun, Wang, & Zhang, 2017; Xu, Hou, & Lee, 2016).
Many barriers affect proper hand hygiene, and the literature
describes many factors for why nurses are nonadherent including high
ZHANG ET AL.
workload, lack of time, type of hospital ward, professional category, and
type of care activity (Sadule‐Rios & Aguilera, 2017). According to WHO
infection prevention and control guidelines (Storr et al., 2017), work-
load is the primary factor affecting the adherence rate of hand hygiene.
High nursing workload adversely affects the quality of patient care,
including augmented HAIs, higher complications, longer hospital stay,
and increased mortality (Aiken et al., 2014; Debergh et al., 2012).
Additionally, high nursing workload not only affects patients' safety
but also harms nursing staff's well‐being, such as being prone to job
burnout, planning to leave, and staffing turnover (Cho et al., 2009;
Chuang, Tseng, Lin, Lin, & Chen, 2016). Currently, there is a well‐
documented shortage of nurses leading to high workload demands
(International Council of Nurses, 2006), which is the most frequent
self‐reported reason for nonadherence (Sadule‐Rios & Aguilera, 2017;
Scheithauer, Batzer, Dangel, Passweg, & Widmer, 2017). However,
these studies use self‐report measuring for hand hygiene and nursing
activities that have the potential for overestimating the adherence to
proper hand hygiene and the effect of nursing workload on the adher-
ence to proper hand hygiene (Jones & Schlegel, 2014). The direct
observation method has been regarded as the gold standard for moni-
toring the adherence to hand hygiene of HCWs (Allegranzi et al.,
2013). Although levels of observational studies about adherence to
proper hand hygiene of HCWs have been extensively reported, each
observation was limited to 20 ± 10 minutes (Garus‐Pakowska, Sobala,
& Szatko, 2013; Megeus, Nilsson, Karlsson, Eriksson, & Andersson,
2015; Sundal et al., 2017). Using this methodology, only a minority of
hand hygiene episodes were captured, and the number of hand hygiene
actions and opportunities could be overestimated, leading to weakness
in the strength of the association between adherence rates and work-
load. The WHO Hand Hygiene Technical Reference Manual (WHO,
2009b) recommends that a health‐care sequence should be observed
from beginning to end. For this reason, observation sessions should
be extended as long as feasible depending on available resources.
2 | METHODS
2.1 | Aims
Few studies have specifically observed adherence to hand hygiene
and workloads for an entire shift in general wards. Thus, the primary
aim of this study was to examine the hypothesis of a negative correla-
tion between nursing workload and adherence to hand hygiene using
a direct observational method. Another aim was to test the adherence
to hand hygiene of nursing staff in the general wards and the possible
factors (eg, wards and shifts) affecting adherence to hand hygiene. The
last aim was to evaluate which of the two hand hygiene methods—
hand washing and ABHR—were more often used by nurses during
routine patient care.
2.2 | Study design and setting
This nonparticipatory observational study was conducted by a single
observer in a one‐to‐one fashion. Adherence to hand hygiene and
nursing workload was assessed on four wards (neurology, cardiology,
ZHANG ET AL.
thoracic surgery, and general surgery) at a teaching hospital in Beijing,
China. The total numbers of professional nurses employed on each
ward were 17, 18, 17, and 21, respectively. The nurse–patient ratios
were 1:7, 1:8, 1:8, and 1:7, respectively. Monthly patient admissions
were 160, 200, 145, and 140, respectively.
2.3 | Participants
A convenience sample of registered nurses was recruited. Nurses
were eligible for the study if they were employed by the study hospital
and volunteered to participate in this study. Participants for observa-
tion were chosen randomly, and the randomization process took place
each morning of the study. The first step in the process was to list all
the nurses present at the start of the shift and then assign numbers to
them. Next, a computer‐generated list was used to randomly select
the numbers of the participants. Each day only one nurse was selected
to be observed by the randomization method.
2.4 | Measurement method
An easy‐to‐master, multifunctional sport stopwatch was used to
measure working hours: KADIO brand, Model KD–1069, accurate to
seconds, manufactured by Jin Tuojia Shenzhen City Electronic
Technology Company Limited, in Longgang district, Shenzhen City,
Guangdong province.
An observation record that included demographic data, working
hours, operational time, and indications for proper hand hygiene
adherence was kept for each participant during each shift observed.
2.5 | Data collection
The data consisted of 64 observation days and were collected by only
one observer to minimize interobserver bias between January 2016
and June 2016. This dedicated observer who was not staff from any
of the participating wards was trained in direct observation of proper
and hygiene practices by the hospital staff who normally monitor hand
hygiene. Observations were made only during day shifts for 8 hours
on weekdays and weekends. In this study, day shifts include three dif-
ferent shift times, including shift times of 8.00 to 4.00, 8.00 to 5.00,
and 8.00 to 6.00 PM. All nurses began work at 8 AM but ended at 4
PM, 5 PM, and 6 PM, respectively. During the course of each shift the
nurses have 15 minutes, 1 hour and 2 hours break depending on the
hours worked. The longer the hours worked, the longer the break.
All subjects were unware of the purpose of the observations. The
observer performed unobtrusive observations without interfering with
the daily routine of patient care or attempting to promote adherence
to hand hygiene to minimize the Hawthorne effect.
Nursing workload has been described as influenced by the num-
ber of staff members, complexity of the diseases experienced by
patients, patient turnover per day, and characteristics of the institution
(Liu, Lee, Chia, Chi, & Yin, 2012; Somensi, Caregnato, Cervi, & Flores,
2018). Many studies define workload using working hours; therefore,
in our study, the definition of nursing workload was the actual hours
worked per shift related to the time of direct and indirect nursing care
3 of 8
activities and timed using a stopwatch (Hurst, 2015; Kunecka, 2015).
Total workload per shift was defined as the sum of all activity (direct
and indirect care to patients) in terms of the work hours of a subject
nurse; the hours actually worked during one shift.
During observations, the observer recorded hand hygiene oppor-
tunities, actions, and duration. In this study, hand hygiene included
hand washing and ABHR. The opportunities for hand hygiene are
those defined by the WHO Five Moments of Hand Hygiene (WHO,
2009a). The observer noted whether appropriate hand hygiene
actions were taken or missed. The WHO Five Moments include the
following: before touching the patient, before clean/aseptic proce-
dures, after suspected exposure to body fluids, after touching the
patient, and after touching objects surrounding the patient (eg, linen
and the patient zone). Adherence to hand hygiene was calculated by
dividing the number of actions to number of opportunities. All study
data were anonymized and treated confidentially.
2.6 | Ethical considerations
The study was approved by the medical director and nursing supervi-
sor. Institution review board approval was not required based on the
institutional policies. Informed consent was obtained orally from all
nurses prior to study participation.
2.7 | Data analysis
Statistics were conducted using SPSS 21.0 software (SPSS Inc
Chicago, Illinois). Continuous data (eg, nursing workload, hand hygiene
adherence, age, and working period) were described with mean or
median. Comparisons between groups were performed with the
Independent‐Samples t Test, and one‐way analysis of variance
(ANOVA) was used for nursing work time. Categorical data (eg, shifts,
departments, education level, and professional titles) were described
with frequency or percentage. Chi‐square test or Fisher's exact test
was used to determine associations between adherences to hand
hygiene and nursing workload and demographics. The Spearman
correlation coefficient was used to examine the correlation between
adherences to hand hygiene and nursing workload, shifts, and depart-
ments. Dummy variables were established to test categorical data.
Multivariate explanatory models of nurses' adherence to hand hygiene
were analysed using multiple linear regression analysis, using enter
forward selection. Missing data were imputed using multiple imputa-
tions. All tests were two‐tailed, and P value <0.05 was considered
statistically significant.
3 | RESULTS
3.1 | Baseline characteristics of participants
Sixty‐four nurses were observed and data were collected during 64
observation sessions (8 hours each), providing 512 hours of observa-
tion time. The group consisted of 64 female participants (100.0%) with
a mean age of 31 (range, 24‐45) years. The mean work experience was
8 (range, 3‐26) years (Table 1).
4 of 8 ZHANG ET AL.

TABLE 1 Factors associated with hand hygiene adherence mean ABHR). Adherence to hand washing was higher than ABHR adherence
(SD) (100% vs 13%), and the time expenditure for the two methods was
Hand significantly different; ABHR took 35 seconds, and hand washing
Hygiene required 69 seconds.
Adherence
Variables n (%) Rate (%) Statistics P value
b
Age (years) 0.97 0.39
20‐30 34 (53.1) 27.50 (5.50)
3.3 | Relationship between nursing workloads and
30‐40 22 (34.4) 25.70 (6.800 adherence to hand hygiene
≥40 8 (12.5) 24.80 (5.00)
During the observation period, the total nursing time that 64 nurses
Working period (years)b 0.39 0.68
spent on direct and indirect nursing care activities was 432.2 hours
<5 7 (10.9) 27.00 (4.31)
(Table 2). The average nursing work time per shift of these 64 subjects
5‐20 49 (76.6) 26.77 (6.31)
was 6.7 hours (range, 6.0‐7.6).
≥20 8 (12.5) 24.80 (5.04)
b Adherence to hand hygiene was inversely proportional to nursing
Educational background 0.87 0.43
workload (Figure 1). To analyse the effects of nursing workload on
Secondary professional 5 (7.8) 27.20 (4.30)
degree hand hygiene adherence, participants were divided into three nursing
Junior college degree 38 (59.4) 25.75 (5.73) workload groups based on shifts worked. A statistically significant dif-
Bachelor degree 21 (32.8) 27.84 (6.62) ference was found between adherence to hand hygiene and nursing
Professional titleb 0.45 0.64 workload (P < 0.01) and department (P < 0.01) (Table 1). There was a
Primary nurse aide 11 (17.2) 27.40 (3.50) correlation between hand hygiene adherence and nursing workload
Senior nurse 45 (70.3) 26.70 (6.60) (Ρ = −0.681, P < 0.001) and shifts (Ρ = 0.256, P = 0.041), as shown in
Supervisor nurse 8 (12.5) 24.80 (5.00) Table 3. Multiple linear regression analysis was applied to explain the
Shiftsb 13.45 0.06
8‐4 23 (35.9) 24.55 (4.63)
TABLE 2 Average daily nursing workload of each department and
shift mean (SD)
8‐5 28 (43.8) 26.88 (5.76)
8‐6 13 (20.3) 29.35 (7.43) Average Daily Nursing
a
Variables n Workload (hours) F value P value
Date 0.20 0.66
Departments 20.81 <0.01*
Workday 47 (73.4) 26.75 (5.81)
Neurology ward 17 6.6 (0.3)
Weekend 17 (26.6) 25.99 (6.46)
b Cardiology ward 12 6.6 (0.3)
Nursing workload (hours)
General Surgery 21 7.2 (0.3)
6.0–6.5 21 (32.8) 31.56 (6.24) 17.22 <0.01
Thoracic surgery 14 6.4 (0.3)
6.5–7.0 23 (35.9) 24.68 (3.22)
Shifts 10.65 <0.01*
7.0–8.0 20 (31.3) 23.42 (4.68)
b 8‐4 23 7.1 (0.3)
Departments 10.44 <0.01
8–5 28 6.6 (0.4)
Neurology ward 17 (26.6) 29.57 (5.88)
8–6 13 6.6 (0.4)
Cardiology ward 12 (18.8) 27.73 (4.25)
General surgery 21 (32.8) 21.68 (3.41) *One‐way ANOVA.
Thoracic surgery 14 (21.9) 29.15 (6.06)
a
Independent‐Samples t Test.
b
One‐way analysis of variance.

3.2 | Adherence to hand hygiene for nurses

A total of 1554 hand hygiene actions and 6010 opportunities were

observed. The overall hand hygiene adherence rate was 26.6%. The
observed adherence to hand hygiene varied by ward, with the highest
rate of adherence to hand hygiene observed in the neurology ward
(30.0%) and the lowest in general surgery (21.7%). There was no
strong evidence of a difference between adherences to proper hand
hygiene among neurology (30.0%), cardiology (27.7%), and thoracic
surgery (29.2%). The age of nurses (P = 0.39), educational background
(P = 0.43), and professional title (P = 0.64) revealed no significant dif-
ferences in adherence rates (Table 1). In addition, nurses were much
more likely to perform hand washing rather than ABHR if there was FIGURE 1 Scatter diagram of nursing workload and adherence to
an indication for hand hygiene action (907 hand washing vs 647 hand hygiene
ZHANG ET AL. 5 of 8

TABLE 3 Correlation of hand hygiene adherence with nursing workload and demographics of nurses (N = 64)

NW (hours) Shifts Departments Ages (years) WP (years) EB PT

ARHH (%)
Ρ value −0.681 0.256 −0.225 −0.231 −0.207 0.055 −0.175
P value <0.001 0.041 0.074 0.066 0.101 0.667 0.166

Abbreviations: ARHH, adherence to hand hygiene; EB, educational background; NW, nursing workload; PT, professional titles; WP, working period.

hand hygiene adherence of nurses using enter with forwards selection.
The multiple linear regression model revealed the rate of adherence to
hand hygiene = 0.92 + (−0.107) × nursing workload, showing that each
one‐point increase in nursing workload resulted in a 10.7% reduction
in adherence to hand hygiene (Table 4).
4 | DISCUSSION
This study offers detailed data on nursing workload and adherence to
hand hygiene using the direct observational method for an entire 8‐
hour shift. The key finding of this study is that the higher the nursing
workload, the lower the adherence to hand hygiene. Increasing evi-
dence points to the important role of nursing workload on adherence
to hand hygiene (Lee et al., 2011; Sadule‐Rios & Aguilera, 2017;
Scheithauer et al., 2017). High workload is a commonly self‐reported
reason for lack of adherence to proper hand hygiene. Sadule‐Rios
reported that 51.0% of nurses believed the main cause of low adher-
ence to hand hygiene was high nursing workloads (Sadule‐Rios &
Aguilera, 2017). El‐Soussi confirmed our results, in their study 71.8%
of nurses viewed high workload as one of numerous barriers causing
low adherence to hand hygiene (El‐Soussi & Asfour, 2017). However,
neither workload nor adherence rate had been measured precisely in
previous research. To date, a few studies have addressed the influence
of nursing workload on adherence to hand hygiene by means of direct
observation methods, but each observation session only lasts
20 ± 10 minutes. One observational study was conducted in a
haematology transplant unit and revealed that hand hygiene adher-
ence was modestly (R = −0.441) inversely correlated with workload
(Scheithauer et al., 2017). Findings from this study were based on
short observation sessions (20‐30 minutes). Our study established a
significant association between nursing workloads and adherence to
hand hygiene by one to one direct observation over 8 hours. The
results of this study further confirm an inverse correlation between
nursing workload and hand hygiene adherence (Ellingson et al.,
2014); Scheithauer et al., 2017). Because of increases in nursing work-
load, nurses have more opportunities to touch patients or the objects
TABLE 4 Explanation of nurses' hand hygiene adherence based on
the sum of independent variables in multiple linear regression model
(N = 64)
95% CI of B
P and lead to negative impacts, with nurses' reports of harm to patients'
Variable B t value Lower Upper
Nursing workload −0.107 −4.746 <0.001 −0.152 −0.062
8.00‐5.00 shift −0.029 −1.780 0.081 −0.063 0.004
8.00‐6.00 shift −0.002 −0.091 0.928 −0.038 0.035
R = 0.776, R2 = 0.517, F = 7.139, P < 0.001; CI, confidence interval.
surrounding the patient, which results in more hand hygiene indica-
tions per unit of time (Lee et al., 2011). In addition, heavy nursing
workload contributes to lack of time for nurses to perform proper
hand hygiene, providing a plausible explanation for the low adherence
to hand hygiene (Scheithauer et al., 2017). These results suggest that a
policy of addressing the most efficient and effective workload alloca-
tion for nurses may have potential impact and increase the effective-
ness of proper hand hygiene practice to guarantee the safety of
patients. Further studies are warranted to determine if decreased
workload leads to improved rates of adherence to hand hygiene.
Findings in this study show that adherence rate to hand hygiene
was poor (26.6%), which conformed with reported adherence rates
of 20% to 40% (Sakihama et al., 2016); Scheithauer et al., 2017).
However, adherence to hand hygiene in our study was less than other
Chinese studies, with adherence rates reported as 52% to 80% (Mu
et al., 2016; Su et al., 2015). The most likely cause for these results
is that the observations in other studies were primarily conducted
for short sessions. Short observation times could lead to biased results
for adherence to hand hygiene, and the true adherence rates could be
even lower with prolonged observation sessions. In this study, nurses
did not perform proper hand hygiene at every opportunity, or they
failed to use correct procedures (Scheithauer et al., 2017). The results
of our study imply that observation of adherence to hand hygiene
helps understand the gaps in practice of nurses and can be used to
plan effective protocols to improve adherence. In the last decade,
many studies have been published about improvement of hand
hygiene adherence among HCWs, such as continuous educational
programmes for nursing staff, infection prevention and control activi-
ties (Chun, Kim, & Park, 2015; Storr et al., 2017), patient participation
in providing positive feedback (Dawson, Wells, Mackrill, & Prevc,
2017; Stewardson et al., 2016), and the use of surveillance systems
(Wetzker et al., 2017). Such strategies can be effective to improve
adherence to hand hygiene and reduce HAIs. At this point, studying
the efficacy of such interventions in China is warranted.
This study identified the influence of department type on nursing
workload. In general surgery (surgical patients with a high‐acuity level
or perioperative patients), the observed workload was the highest
(7.2 hours). Similar results were obtained by Sakihama et al. (2016),
who conducted direct observations on 13 diverse units across 4 par-
ticipating hospitals and found that nurses in surgical wards had highest
workloads. Nurses' workload can increase with shortages of personnel
clinical conditions and higher rates of nursing care activities left
undone (Griffiths et al., 2014). This study suggested that the surgical
unit may be understaffed with a correspondingly high nursing work-
load, and the implication is that with more patients to be taken care
of and more hand hygiene, opportunities are linked with a resultant
6 of 8
decrease in adherence to hand hygiene. Nursing workload may nega-
tively influence patient safety outcomes, such as increasing the risk
of pressure injury, length of hospital stay, and cross‐transmission of
nosocomial pathogens (Corchia et al., 2016; Debergh et al., 2012).
Therefore, the measurement of nursing workload in each shift is cru-
cial for nurse managers to modify the organization of services that
are required for pursuing effective and efficient nursing care activities.
In our study, we found that the mean duration required for hand
washing and ABHR were 69 and 35 seconds, respectively. WHO
(2014) also suggests a benefit of ABHR in saving time, as a convenient
and cost‐effective surrogate for hand washing to improve adherence,
as well as decreasing HAIs. It is crucial that nurses are consciously
aware of their usage of ABHR, a recommended prospective solution
in high‐demand wards like surgical units (Harnoss et al., 2014). Results
from several studies have favoured the use of ABHR over hand wash-
ing with soap (Lai, Foo, Low, & Naidu, 2012; Murphy & Chua, 2016).
Among the 13 clinical studies that compared the effects of removing
microorganism of ABHR with hand washing for use by HCWs, 12
reported that ABHR was superior to soap, and one found the strate-
gies to be equivalent (Ellingson et al., 2014). In addition, hand washing
has significant disadvantages compared with ABHR, such as higher
time consumption or the requirement of a wash basin for washing
and rinsing (Schmitz et al., 2014). In this study, nurses preferred hand
washing to ABHR when there was an indication for hand hygiene
action, and low adherence to proper hand hygiene can be related in
part to low ABHR adherence. This finding is different from previous
studies related to the usage rates of two hand hygiene strategies.
The study of Lebovic, Siddiqui, and Muller (2013) study offers support
that units using less soap and more ABHR are inclined to have higher
hand hygiene adherence with a higher ABHR adherence (74%) as
opposed to hand washing adherence (26%), but auditors in this trial
only observed HCWs' hand hygiene for 20 minutes in each session
on weekdays, which may weaken their results. In this study, the
discrepancies in ABHR adherence rates likely occurred due to the
different observation times that lasted for 8 hours per session rather
than 20 minutes (Garus‐Pakowska et al., 2013). The main obstacles
proposed for use of ABHR include correlation with chronic alcohol
ingestion that would result in an increased risk of psychological disor-
ders and heart disease (Bauer‐Savage, Pittet, Kim, & Allegranzi, 2013),
as well as its reportedly unpleasant smell (Cargiulo, 2007). Specific rea-
sons for the less frequent use of ABHR need to be further explored.
4.1 | Study limitations
Several limitations should be noted. First, the study was performed at
a single centre and observations were carried out on only four wards;
a multicentre study should be conducted in all types of hospital units
to further verify the generalizability of the results. Second, observa-
tion bias was generated by the presence of an observer, who had
the potential to influence the behaviour of the subject although this
bias was minimized by keeping observations covert. Another limitation
of this study was that only day shift nurses were investigated. It
should be noted that generally workload and staffing patterns are
different on the night shift, generally with fewer nurses scheduled to
ZHANG ET AL.
work and fewer hand hygiene opportunities. The relationship between
nursing workload and adherence to hand hygiene among nurses on
other shifts needs to be further explored. Finally, we did not explore
the reasons why adherence to ABHR was much lower than adherence
to hand washing, so this is an area for further research.
5 | CO NC LUSIO N
This nonparticipatory observational study offers detailed data of hand
hygiene practices and nursing workload for an entire 8‐hour shift.
Adherence to hand hygiene was poor and independently associated
with actual nursing workload. In accordance with other studies, nurses
in this setting were observed having a high workload, which contrib-
uted to lack of time to perform proper hand hygiene.
Inadequate adherence to hand hygiene points to the necessity of
providing targeted interventions not only to encourage proper hand
hygiene behaviour of HCWs but also to enhance their understanding
of potential impacts of effective hand hygiene in guaranteeing the
safety of patients. Future research should also identify factors
influencing nursing workload and rationally allocate nursing resources
according to the needs and levels of care for patients.
ACKNOWLEDGEMENTS
We would like to thank all the nursing staff at the University Teaching
Hospital of Beijing who took part in the study for their active partici-
pation and confidence in the researchers.
CONFLIC T OF INT E RE ST
The authors declare no conflict of interest.
AUTHOR SHIP STATEMENT
YW, XK, and SZ were responsible for the study design. YW, XK, KVL,
and SZ did the data analysis and drafted and revised the manuscript.
All listed authors meet the authorship criteria, and that all authors
are in agreement with the content of the manuscript.
ORCID
Shan Zhang https://orcid.org/0000-0002-7426-3597
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How to cite this article: Zhang S, Kong X, Lamb KV, Wu Y.
High nursing workload is a main associated factor of poor hand
hygiene adherence in Beijing, China: An observational
study. Int J Nurs Pract. 2019;e12720. https://doi.org/
10.1111/ijn.12720