Improving hand hygiene among healthcare workers

Submitted by ICN
May 5, 2021

Improving hand hygiene among healthcare workers with the use of data from a monitoring system – the effect of behavioural interventions, Denmark


Contributor: Anne-Mette Iversen, Clinical Nurse Specialist, Aarhus University Hospital, Denmark

ICN supports the WHO annual campaign, SAVE LIVES – Clean Your Hands” held on World Hand Hygiene Day, 5 May. We bring you the story of a nurse in Denmark who invented an electronic monitoring system to measure hand hygiene.

One morning in 2015, at the Department of Oncology, Anne-Mette Iversen, a Clinical Nurse Specialist at Aarhus University Hospital in Denmark was caring for a young woman with breast cancer. The cancer had responded to chemotherapy, but she had acquired a serious bacterial infection. As her nurse, Anne-Mette was administering antibiotics and cleaning her surgical wound. She thought about the challenging elements in the practice of good hygiene. In Denmark, 60,000 patients acquire a healthcare associated infection during in-patient care each year. These infections are detrimental for oncology patients due to their weakened immune systems. Compliance to hand hygiene guidelines is crucial for infection prevention. At her hospital, flyers, stickers, training and posters had all been used to improve staff hand hygiene compliance using. Nothing had worked.

Anne-Mette’s colleagues stated they performed hand hygiene 100% of the time, but that was not what she saw in practice. It is a common cooccurrence for individuals to say, and even believe, that they are performing proper hand hygiene during all critical moments of care, but they overestimate their performance (known as the Dunning-Kruger effect, a cognitive bias). Anne-Mette knew she had to create behaviour changes to see results.

With limited experience in behaviour change, Anne-Mette mobilised a group of behavioural specialists, facility leaders and engineers, who agreed to help improve hand hygiene at the hospital. After discussions, they concluded that if staff did not know their hand hygiene behaviour, then they could not change it. While direct observation is important in measuring compliance, the method leaves gaps in tracking all hand hygiene opportunities. By developing an electronic monitoring system based on WHO’s Five Moments for Hand Hygiene, they would be able to accurately measure compliance rates among staff and tailor hand hygiene messages accordingly.

They developed a solution: Sani nudge1 hand hygiene, using sensors on alcohol dispensers, staff name badges and throughout key areas around the oncology department, such as staff toilets, medication rooms and patient bedsides. The system determines whether a staff member has encountered a critical moment for hand hygiene (e.g. in contact with a patient) and whether alcohol-based hand rub was used to clean their hands.

The system was initially installed and tested at two university hospitals in Denmark. It is a unique solution because it considers previous workflow rather than looking at hand hygiene compliance through isolated situations. For instance, a healthcare worker could go from the toilet to the office and subsequently to a patient room. The system measures compliance 24 hours a day. Compliance data is available via an online dashboard, making it easier to identify areas, staff groups and times of day when an improvement needs to be made. The system sends weekly emails to each individual staff member showing their individual compliance level. The use of data proved to be useful for both leaders and nurses to visualise their hand hygiene practice.

The system has been validated and the data is now used in research projects to investigate the effect of different behavioural nudges, such as light-guided nudges and weekly feedback, on staff compliance. The system is now implemented in hospitals and nursing homes throughout Denmark and in other six countries. Since the beginning of the COVID-19 pandemic, the data has also been used in another research project to investigate if the data can be used for automatic contact tracing at hospitals.

Nurses are crucial to the success of this solution. While the system provides data on the behaviour of healthcare professionals within the hospital, a head nurse or a nurse, known as a “Hygiene Mentor”, is responsible for following up on the data and ensuring the team is motivated and doing improvement work. The system provides them with the data to do this with credibility.

Since its development in 2015, the system has been clinically proven to improve hand hygiene in hospitals2. A newly published study shows that a group of nurses in a university hospital in Denmark improved their hand hygiene compliance from 27% to 55% in patient rooms and 39% to 80% in working rooms when receiving light guided nudging and weekly performance feedback3.

Find out more at

1 Nudge is a concept in behavioural economics, political theory, and behavioural sciences which proposes positive reinforcement and indirect suggestions as ways to influence the behaviour and decision making of groups or individuals. (Wikipedia)
2 Iversen AM et al. (18 October 2019). Clinical experiences with a new system for automated hand hygiene monitoring: A prospective observational study. Am J Infect Control. 2019;48(5):527-33. Available at:
3 Iversen AM et al. (10 November 2020). Light=guided nudging and data driven performance feedback improve had hygiene compliance among nurse and doctors. Am J Infect Control. 2020: Available at:

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