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Table 3 Quotes related to the main themes of Flottorps’ comprehensive checklist

From: Exploring determinants of hand hygiene compliance in LTCFs: a qualitative study using Flottorps’ integrated checklist of determinants of practice

Flottorps’ main themes Subthemes Category Representative quotes
1. Guideline factors Recommendation Clarity ‘Guidelines are fine if they are concise and clear. But not when I have to read a whole letter-sized page before I can begin. I would like to have a picture with five bullet points instead of the three pages we have now.’ (focus group 5)
Accessibility of the recommendation ‘There is a protocol for hand hygiene.... First you have to start your computer to search for the protocol. It has not been posted in a visible spot.’ (focus group 5)
2. Individual health professional factors Knowledge and skills Domain knowledge ‘I suppose that alcohol-based handrub is good for after washing your hands. But if you do not wash hands and only use the handrub, that is not good.’ (focus group 1)
Cognitions (including attitudes) Expected outcome ‘Yes, I believe that, but it [hand hygiene] will not prevent 100% of everything [infections]. I do not believe that.’ (focus group 2)
Intention and motivation ‘I put on gloves to protect myself. I have not really thought about it [hand hygiene] being necessary for the resident, I do it purely for myself. More for myself than for the resident.’ (focus group 4)
Emotions ‘I am very sensitive to someone’s hygiene or lack of it. This morning I realised that I had washed my hands four times while I treated that man.’
Interviewer: ‘Can you describe the poor hygiene of a resident?’
‘Some residents cannot take care of themselves or are too passive or inactive, and I know the nurses do that for them. I take other things into account: what their nails look like and how they smell.... It is very subjective, of course.’ (focus group 2)
Professional behaviour Nature of the behaviour ‘Then you are busy with the resident, and sometimes you think, oh, I have to go get that. Then you have to take off [the gloves], wash your hands, go outside.... It should be done, but it is not done.’ (focus group 3)
3. Patient factors Patient needs   ‘Definitely with us on the psycho-geriatric ward [there is a lot of physical contact with residents]. There is a lot of cuddling.’ (focus group 2)
Patient preferences   ‘Yes, but I believe that when I shower someone with gloves on, it creates a distance.... Then I think how would I like it, and I would not like it if someone approached me with those blue gloves on.’ (focus group 1)
Patient behaviour   ‘I believe that washing my hands beforehand is not relevant at the moment [when a resident suddenly becomes unwell].... It so happened that I was outside to eat and smoke, and when I came back in a woman became unwell.... My hands were not clean, but the woman came first.’ (focus group 4)
4. Professional interactions Communication and influence   ‘Look, if you see that your colleague is not washing her hands, after, for instance, faeces, you think: What a filthy colleague... but you do not always see that. If someone is working alone, then I cannot check whether she has washed her hands.’ (focus group 4)
5. Incentives and resources Availability of necessary resources   ‘Anyway, it is encouraging that soap and towels are available in each resident’s room. That is encouraging, but they need to be replenished. That does not always happen.’ (focus group 1)
  Continuing education system   Interviewer: ‘Did you receive any education about hand hygiene or did the geriatrics specialist provide information?’
‘I don’t know.’ (focus group 1, Participant 1)
‘No, he only said to me one time, “You have to wash your hands or else it is not effective”’. (focus group 1, Participant 2)
6. Capacity for organisational change Regulations, rules, policies   ‘The cleaning staff used to do a lot, cleaning the kitchens, etc. Economising has done away with all that. So they have to do the same work in less and less time. A lot of things have now been assigned to the care that we have to do ourselves.’ (focus group 5)
Priority of necessary change   ‘Alcohol [handrub] was only available during the Noro virus outbreak. Everything is ready for something like that. We are only really alert when there is an outbreak.’ (focus group 1)
Monitoring and feedback   ‘It’s a pity that there is no feedback. But if we had known that we had really bad marks, maybe we would...’ (focus group 4, Participant 1)
‘Have given it more attention.’ (focus group 4, Participant 2)
  1. Adapted from Flottorps’ et al. [16] checklist