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HandHygieneCriticalAppraisal.pdf
2022, Vol. 29(2) 436 –447
Hand hygiene monitoring technology: A descriptive study of ethics and acceptance in nursing
Michael Meng Albert-Ludwigs-University Freiburg, Germany; Federal Institute for Vocational Education and Training (BIBB), Germany
Anna-Henrikje Seidlein University of Greifswald, Germany
Christiane Kugler Albert-Ludwigs-University Freiburg, Germany
Abstract Background: Nosocomial infections represent a serious challenge for healthcare systems worldwide. Adherence to hand hygiene plays a major role in infection prevention and control. These adherence rates can be improved through behaviour tracking innovations. This requires the systems to be widely implemented and accepted. Therefore, both a systematic analysis of the normative issues related and the evaluation of technology acceptance are equally important. Objectives: To explore and describe relevant aspects regarding the acceptance of technology and ethical implications using a tracking device to measure and improve adherence to hand hygiene. Research design: A quantitative study with a descriptive design was performed. Participants and research context: A total of 75 questionnaires were collected in three hospitals in Germany. Acceptance of technology was measured with n ¼ 60 participants (n ¼ 50 nurses; n ¼ 9 physicians; n ¼ 1 not disclosed) and ethical assessment with n ¼ 15 participants (nurses only). Ethical considerations: Ethical approval for this study was obtained from the institutional review board. Findings: The acceptance of technologies improving hygiene in general was good (median ¼ 80.5, interquartile range ¼ 28, range: 0–100). The experience with technologies in general (median ¼ 48.5, interquartile range ¼ 57, range: 0–100) and the acceptance of the specific technology (mean ¼ 82.23, standard deviation ¼ 15.16 (range: 23–138)) was moderate. There was a significant positive correlation between the acceptance and experience of technology in general (r ¼ 0.217, p ¼ .025). Ethical concerns played a minor role. The need for practical support was a key topic. Discussion: Study participants accepted technologies improving hygiene; however, the specific device implemented was only moderately accepted. This creates specific opportunities in the implementation process for higher later acceptance. More practical support and an increase in
Corresponding author: Christiane Kugler, Institute of Nursing Science, Faculty of Medicine, Albert-Ludwigs-University Freiburg,
Breisacher Straße 153, 79110 Freiburg, Germany.
Email: [email protected]
Nursing Ethics
ª The Author(s) 2021 Article reuse guidelines:
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Original Manuscript
Meng et al. 437
experience may create opportunities for device implementation with high acceptance and low ethical concerns. Conclusion: Study results indicate a vast potential for improving the implementation process of hand hygiene technologies. Ethical concerns in this study did not seem to be a relevant barrier for successful implementation of hand hygiene technologies.
Keywords Ethics, infection prevention and control, nurse, technology acceptance, theories, model, ethical assessment
Introduction
Since hand hygiene is important but still insufficiently followed, it is supported by tracking technologies to
increase adherence. The expectations placed on these devices are high but their implementation and
evaluation hold numerous challenges,1,2 and quite a few of these innovations fail in practice due to incon-
venience and/or inaccuracy.3 In addition to the focus on the efficacy of these systems,4 a systematic analysis
of the normative issues related is equally important for both the nurses themselves and the patients.
Empirical information about the effect and impact of their implementation is fundamental to the ethical
evaluation. This responsibility is also formulated in the “ICN Code of Ethics for Nurses” that demands from
them that “the nurse, in providing care, ensures that use of technology and scientific advances are compa-
tible with the safety, dignity and rights of people”5 (p. 3). Therefore, this paper aimed to identify possible
ethically relevant aspects associated with the use of electronic monitoring systems for hand hygiene
surveillance purposes.
Background
Nosocomial infections pose a major threat to healthcare systems at the micro, meso and macro level.6,7 Inter
alia, they lead to prolonged hospitalization, increase patients’ morbidity, raise mortality rates and cause
significant extra costs for treatment.8 The healthcare professionals’ (HCPs) ethical principle of doing no
harm (“non-maleficence”), thus, entails high-quality hand hygiene aiming to maximise patient safety.
However, nosocomial infections in Germany are currently estimated at 400,000 to 600,000 cases per year.9
Although evidence suggests that hand hygiene is an effective way to prevent nosocomial infections and
HCPs possess adequate knowledge and hold positive attitudes,10 their adherence In contrast to the majority
of publications on this topic, the authors refer to the term ‘adherence’ instead of ‘compliance’. This is
especially due to the fact that the term stresses the knowledge and agreement of nurses with guidelines for
good practice concerning hand hygiene. Adherence emphasises nurses’ active professional role rather than
viewing them as persons who are expected to do what they are told. However, when citing other studies, the
original wording of the authors is used. rates remain inadequate. Adherence and compliance cannot be used
synonymously.11 The main difference is the integration of the perspective of the healthcare professional in
the term adherence.12 A recent review reports a mean hand hygiene compliance of 59.6% fromHCPs.13 The
World Health Organization stresses that “evaluation and repeated monitoring of a range of indicators
reflecting hand hygiene infrastructures and practices [ . . . ] [are] a vital component of any successful hand
hygiene campaign”.14 Several approaches, such as education and different forms of reminders, are thus,
followed to improve this compliance with uncertain evidence for their success.15
As solely conventional measures/programmes to enhance adherence lack long-term effectiveness and
require high staff resources (e.g., for periodic non-participant observations),15 new solutions and acquired
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techniques are increasingly requested. Electronic monitoring systems with feedback system are such an
innovation that aims to enhance meeting disinfection standards through increasing adherence. A recent
systematically performed review indicates that these systems hold the potential to increase adherence rates
between 6.40 and 54.97%.12 Such devices aim to capture whether hand disinfection is performed when it is
indicated, e.g., according to the World Health Organization’s “5 Moments for Hand Hygiene”.16
The philosophy of technology, respectively ethics of technology has been a matter of concern for a long
time with related issues such as responsibility and the possibility of moral agency17 and thus also the -
potential positive or negative - influence on the relationship with the patient.18 In the nursing ethics
literature, both fundamental negative and positive attitudes towards the integration of technology in nursing
care can be found19 along with approaches that seek to reconcile excessive optimism and pessimism and
strive for a fruitful reorganisation.20 However, ambivalent attitudes are the most common ones.19 Our work
is guided by the premise that good care practice is characterised, among other things, by adherence to
evidence-based standards that can help improve patient outcomes. Technologies should be established
“wisely on behalf of ethical patient care”.21 We thus furthermore start from the premise, that technological
innovations in nursing care themselves are not neutral but value-laden as they are created to reach this
normative claim.
From a methodological point of view, bioethical debates traditionally proceed by means of theoretical
analysis concerning moral-philosophical principles and reflecting on how to balance them and thus, do not
capture nor integrate the empirical perspectives. Recently, bioethics applied the methods of socio-empirical
research, e.g., on attitudes.22 Moreover, bioethical research has recently established its own distinct meth-
odology, namely empirical-ethical research by which “empirical social scientific analysis is integrated with
ethical analysis in order to draw normative conclusions”.23 The present project used the methods of
empirical social research with the guidance of an ethical framework (MEESTAR) to explore the problem
area. We follow the view of Pols24 that all technologies have specific impacts that can only be understood if
they are studied empirically. This is carried our by collecting data to analyse the relationships between
HCPs and the technologies they use.24
Concerns about such technologies were raised particularly regarding a possible change in interpersonal
interaction, data security, and the underlying concept of humans as “individuated, independent and rational
agents”.22 According to Meng et al.,12 “transparency and confidentiality” - which refer directly to ethical
challenges arising from these innovations - are key elements that are crucial for the acceptance of electronic
hand hygiene monitoring systems.
Objectives
The study aims to explore and describe relevant aspects regarding the acceptance of technology and ethical
implications using technology to measure and improve the adherence of hand hygiene.
Research design
A cross-sectional study design has been used and data were collected after implementation of a wearable
hand hygiene technology at three hospitals across Germany. The tracking devices were able to track the
user’s behaviour related to hand hygiene. The device used in this study was wearable technology. The
sensor was attached to the clothes of the participants. The sensor assessed the amount of ethanol in the air
and calculated whether proper hand disinfection was performed. The hardware (fully operational) was in a
final evaluation phase at the time of data collection. Further technological development based on the data is
intended. This study presents a descriptive approach. Furthermore, the wearable technology implemented
was able to provide hygiene behaviour–related real-time feedback to the user. This was possible because of
Meng et al. 3
Meng et al. 439
(1) the technology’s ability to assess whether a hand disinfection took place or was not performed and (2) to
communicate with patient beacons.
The tracking technology was able to follow the user’s movement, the proximity to a patient and the
adherence to hand hygiene. If no hand disinfection was performed, the technology was able to provide
haptic (vibration), audio (signal tone) and visual (led) feedback. Ethical approval for this study was granted
by the institutional review board at University Medicine Greifswald. This report has been prepared in
accordance with the statement ‘strengthening the reporting of observational studies in epidemiology’
(STROBE).25
Instruments
This study focused on two central aspects regarding ethical considerations when implementing new track-
ing technologies in healthcare settings. First, we assessed the acceptance of technology utilising the ‘unified
theory of acceptance and use of technology’ (UTAUT).26,27 The UTAUTwas initially developed based on a
comprehensive review of eight existing theories: ‘Theory of Reasoned Action’, ‘Technology Acceptance
Model’, ‘Motivational Model’, ‘Theory of Planned Behaviour’, ‘Combined Technology Acceptance Model
and Theory of Planned Behaviour’, ‘Model of PC Utilisation’, ‘Innovation Diffusion Theory’ and ‘Social
Cognitive Theory’.26 Second, we assessed potential ethical problems utilising the ‘Model for the Ethical
Evaluation of Socio-Technical Arrangements’.28 The MEESTAR supported the assessment of potential
ethical challenges regarding the hand hygiene tracking technology implemented. It can be used for a wide
range of technologies and is designed to identify ethically problematic effects in a structured way and is,
therefore, well-suited to achieve the goal of this study. TheMEESTAR is intended to assist the evaluation of
technical innovations that are under development.29 It can be applied during pilot implementation in an
iterative process to identify potential problems, obstacles and potential for improvement that are to be
addressed in the next step.
Technology Acceptance Questionnaire in accordance with the UTAUT theory. Technology acceptance was
assessed with a standardised questionnaire developed by Spagnolli et al.,30 which was forward and back-
ward translated as described by Acquardo et al.31 in German by two independent English native speakers
and adapted in a culturally sensible way for the German population by an independent work group. The
translated questionnaire30 was based mainly on the UTAUT theory.26 The questionnaire contains 23 items
on 11 dimensions: attitude, anxiety, facilitating conditions, perceived usefulness, effort expectancy, beha-
vioural intention, psychological attachment, perceived privacy, perceived enjoyment, perceived comfort,
transparency. These dimensions were assessed on a five-point Likert-type scale. An overall sum score for
the specific technology was calculated based on the raw scores of each dimension. All values have been
transformed, leading to a possible score range between 23 (lowest possible acceptance) and 138 (highest
possible acceptance). Furthermore, acceptance with technologies for improving hygiene in general and the
overall experience with such wearables in general were assessed using a one-item visual analogue scale
ranging between 0 (least acceptance or, respectively, least experience) and 100 (maximum acceptance or,
respectively, maximum experience). These two visual analogue scales were assessed to analyse a potential
link between experience in general, acceptance in general and the overall sum score of the 11 UTAUT
dimensions for the acceptance of the specific technology. In addition, one goal was to describe potential
differences in acceptance between already implemented technologies for improving hygiene in general and
the acceptance of the newly developed specific wearable technology.
Ethical assessment according to the MEESTAR model.MEESTAR does not refer to a specific ethical-theoretical
framework concerning the ethics/philosophy of technology. The instrument does not aim for a normative
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evaluation of the technical innovation but rather to identify possible normative pitfalls by as many relevant
stakeholders as possible. A normative evaluation is not intended by the model and cannot be achieved with
its application.28
TheMEESTARmodel offers a framework drawing on seven ethical dimensions (care, autonomy, safety,
justice, privacy, participation, self-conception) on three levels (social, organisational, individual) to facil-
itate structured analysis.32 The dimension ‘participation’ was excluded for the purpose of the economy of
the questionnaire as it was not applicable for our sample. The dimension of self-conception ‘refers to the
philosophical-anthropological understanding of the human being and the idea that individuals have of
themselves’28 (p. 251, own translation). The author assumes that the use of technology changes the
self-conception of all individuals who are directly and indirectly involved and affected by it.28
A questionnaire – based on the dimensions of MEESTAR – was developed instead of the face-to-face
focus group interviews scheduled initially due to the COVID-19 pandemic being a threat for healthcare
worldwide.33 This decision was made considering the hygiene requirements and the increased workload and
limited time resources of the HCPs. Utilising this approach, it was possible to evaluate ethical aspects of
technology in infection prevention and control at a time when these technologies are needed most.34
This questionnaire assessed the ethical dimensions on a seven-point Likert-type scale. The latter was
used to provide a sufficiently wide range of possible answers. Only medians, interquartile ranges (IQRs) and
frequencies are presented in this sub-analysis. Therefore, the individual items of the questionnaire are only
described in terms of content. In addition, a visual analogue scale ranging between 0 (ethically problematic)
and 100 (ethically unproblematic) was presented.
Statistics
All variables were tested for their normal distribution using the Kolmogorov–Smirnov test. The latter
indicated that no variable was normally distributed (all p < .042), except the overall sum score for accep-
tance based in the 11 dimensions of the questionnaire (p > .200). According to the distribution of the
variables, mostly medians and IQRs and nonparametric correlation coefficients are presented. Kendall’s
Tau rank correlation procedures were used to test the correlation between the two visual analogue scales and
the overall sum score of the questionnaire because of its robustness in the context of outliners and its
statistical efficiency.35 The level of significance was set at <0.05 a priori. All analyses were performed with
SPSS version 24.
Participants and research context
Hospital management was approached to invite potential study participants. Head nurses of the wards
distributed the questionnaires. Data for the Technology Acceptance Questionnaire (TAQ) were collected
in three German hospitals located in two different federal states and data for MEESTAR were collected in
one German hospital. The participants used the tracking technology actively for at least 1 month prior to the
distribution of the questionnaires. A total of 60 persons participated in the study. All 60 participants were
assessed with the TAQ, and n ¼ 15 within the sample were assessed with the questionnaire based on
MEESTAR. The MEESTAR was developed as a framework for focus group interviews but had to be
adapted as a questionnaire for this study due to the COVID-19 pandemic. This resulted in a complex,
uneconomic questionnaire. Due to this fact, only 15 participants in one hospital filled out the questionnaire.
This resulted in N ¼ 75 questionnaires based on 60 persons.
Meng et al. 5
Meng et al. 441
Ethical considerations
Ethical approval for this study was obtained from the institutional review board at University Medicine
Greifswald (BB 156/17). All data were assessed anonymously. The respective works council approved the
questionnaire and the conduct of the survey.
Findings
Demographics
Technology acceptance (TAQ). A total of 60 participants filled in the TAQ questionnaire, which was based on
the UTAUT model and the study by Spagnolli et al.30 regarding the acceptance of technology. The
participants were an average of 36 years old (mean (M) ¼ 36.1, standard deviation (SD) ¼ 10.0). Most
participants were female (n ¼ 39). Most participants were from the nursing profession (n ¼ 50),
nine participants were physicians and one participant did not disclose his or her profession. The Mann–
Whitney U test indicated that both professional groups were comparable. The test showed no significant
differences between the professional groups (nurses vs physicians) regarding (1) the acceptance in general
(p > .294), (2) experience in general (p > .051) and (3) the sum score of the questionnaire (p > .330).
MEESTAR. Fifteen participants filled in the questionnaire, which was based on MEESTAR for the ethical
evaluation. Nine participants were female, six were male and all were from the nursing profession. Parti-
cipants were an average of 35 years old (M ¼ 35.2, SD ¼ 10.4).
Main findings: technology acceptance (TAQ)
Table 1 shows the descriptive analysis for each of the 11 dimensions of the questionnaire. All values were
transformed, with higher values equalling a positive outcome. The sum score for all dimensions of the
questionnaire wasM ¼ 82.2, SD ¼ 15.1 (range: 23–138; theoretical meanMt ¼ 80.5). The visual analogue
scale for assessing the acceptance of technologies improving hygiene in general showed good acceptance:
median (Mdn) ¼ 80.5, IQR ¼ 28 (range: 0–100). The visual analogue scale for assessing the experience
with technologies, in general, showed moderate experience: Mdn ¼ 48.5, IQR ¼ 57 (range: 0–100).
Table 1. Descriptive analysis of the acceptance of technology.
Dimension (number of items) Mdn IQR Possible score range
Attitude (3) 14 4 3–18 Anxiety (3) 6 3 3–18 Facilitating conditions (2) 4 2 2–12 Perceived usefulness (3) 12 7.5 3–18 Effort expectancy (2) 9 2 2–12 Behavioural intention (1) 4 2.75 1–6 Psychological attachment (2) 8 4 2–12 Perceived privacy (2) 4 1 2–12 Perceived enjoyment (1) 4 3 1–6 Perceived comfort (1) 3 2 1–6 Transparency (3) 11 6 3–18
Mdn: median; IQR: interquartile range.
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442 Nursing Ethics 29(2)
Table 2. Descriptive analysis of the ethical assessment.
Dimensions and variables
N ¼ 15 Data in absolute frequencies (N ¼ 15)
Mdn IQR
Do not agree at all (1)
Do not agree (2)
Rather not
agree (3) Neutral (4)
Rather agree (5)
Agree (6)
Totally agree (7)
Self-conception It is important for me to get practical support in using the device
5 2 0 0 3 3 2 7 0
I receive practical support from my superiors
5 2 0 1 1 5 2 6 0
I receive practical support from my colleagues
5 2 0 1 1 4 2 7 0
Autonomy It is possible for me to respect patient autonomy when using the new device
5 4 1 3 1 0 3 6 1
Care The device has an impact on the development of the relationship with my patients
2 2 4 6 3 0 1 1 0
Patient autonomy is very important to me
6 1 0 0 0 1 4 8 2
I think that the device has negative consequences for the patient
2 1 3 8 2 0 2 0 0
Safety I think that the device endangers the safety of the patient
2 1 4 8 2 1 0 0 0
I think that the device endangers the safety of the colleagues involved
2 1 4 8 2 1 0 0 0
I think that the device has a positive effect on hand hygiene
6 1 0 0 1 2 3 7 2
Principle of justice I would like the device to be transferred to other areas of the hospital
5 2 0 1 2 3 2 5 2
I am influenced by the fear of possible legal consequences in my work in general
3 1 0 2 8 3 1 1 0
I am influenced by the fear of possible legal consequences in my work with this device
2 1 2 6 4 2 1 0 0
The new technology is responsible for a greater lack of time
3 3 1 3 4 1 4 2 0
Privacy I think that the device restricts the patient’s right to privacy
2 1 3 8 3 1 0 0 0
I think that the device restricts my right to privacy as an employee
2 2 1 7 3 1 3 0 0
I think that the device restricts the team’s right to autonomy
3 2 1 5 4 2 3 0 0
Mdn: median; IQR: interquartile range.
Meng et al. 7
Meng et al. 443
There was a significantly positive correlation between the two visual analogue scales (acceptance and
experience; r ¼ 0.217, p ¼ .025). There was no significant correlation between the sum score of the
questionnaire for the specific technology and the two visual analogue scales for assessing the acceptance
of technologies improving hygiene in general and experience with these technologies in general.
Main findings: ethical assessment. Table 2 shows the medians, IQRs and frequencies for all items assessed in
this sub-analysis.
Participants considered it important to receive practical support (self-conception) with the device and
resume that they had already received it from colleagues and superiors. Patient autonomy, which is rated to
be of utmost importance for nursing staff, is not endangered due to the implementation of the devices
according to the study participants. They are not afraid of negative consequences regarding the care
relationship, nor of threatening their own or the patient’s health as a consequence of implementing the
hand hygiene monitoring device. Participants expected the potential impact on hand hygiene to be positive.
They also see no threat to their privacy nor do they fear legal consequences (justice) due to using the
device.
In addition, the questionnaire used a visual analogue scale to assess the participant’s overall ethical
evaluation of the tracking technology in question.
The visual analogue scale for assessing the overall ethical evaluation of the participants showed that they
perceive the technology as ethically rather unproblematic (Mdn ¼ 83, IQR ¼ 40, range: 0–100).
Discussion
This study provides findings on the acceptance and ethical challenges related to the implementation of a
hand hygiene tracking system. According to TAQ, the hand hygiene tracking technology was accepted by
nurses and physicians across all hospitals included. There was no difference in the acceptance and expe-
rience between nurses and physicians. Descriptive statistics indicate that there was more acceptance for
technologies improving hygiene in general, compared to the specific acceptance of the technology pre-
sented. The experience with technologies improving hygiene, in general, was moderate. Descriptive sta-
tistics show a significantly positive correlation between the general acceptance and experience of
technology improving hygiene. In addition, according to MEESTAR, the technology was assessed as
ethically unproblematic by the study participants (nurses only). It was important for most study participants
to receive practical support with the device.
The acceptance of technologies (TAQ) improving hygiene in general was higher compared to the
specific acceptance of the technology presented. This may be interpreted as a fundamental willingness but
not specifically with the current technology. Especially the UTAUT categories anxiety, facilitating condi-
tions, perceived privacy and perceived comfort can possibly help to generate a higher acceptance of the
specific technology. Descriptive statistics showed that these variables scored within the lower half of their
respective scale ranges. It seems that participants had high levels of anxiety regarding the technology when
using the device in question. Furthermore, they were not satisfied with their organisational support of the
implementation process as the low scores of facilitating conditions demonstrate. Participants rated per-
ceived privacy relatively low. This creates a possibility for improved communication of data transparency
and confidentiality, which has the potential to enhance later acceptance of tracking technology in infection
prevention and control.7 In contrast to these results, the ethical assessment showed rather no privacy
concerns. This is possibly a result of the testing context. Participants may associate different aspects of
privacy in the context of ‘ethical assessment’ versus the context of ‘assessment of acceptance’. The last
scale, perceived comfort with the wearable technology, creates a chance for redesigning the specific
technology where the tracking device is not perceived as an obstacle and is potentially more accepted.7
8 Nursing Ethics XX(X)
444 Nursing Ethics 29(2)
Remmers states that ‘the acceptance of new technologies needs to be evaluated according to the extent to
which their effects are compatible with the normative demands and integrity interests (self-determination,
security) of the persons concerned’36 (own translation). Regarding the compatibility with normative
demands, no ethical problems or concerns were identified in this study.
In contrast to similar studies that investigated the use of tracking systems in other care contexts – for
example, in individuals with dementia37,38 – and identified serious ethical problems for the nurses and a
shift in professional roles, the use of a tracking system regarding hand hygiene does not seem to raise any
ethical concerns. This may be due to the fact that nurses are not considered as a vulnerable group, respec-
tively, that they do not perceive themselves to be particularly vulnerable in this regard. Nevertheless, it
should not be neglected that professional caregivers can also be vulnerable – not least, because of the current
working conditions.39 The precarious conditions of their work environment may put them in a position
where they might violate their own moral values, including high standards of hygiene as a component of
patient safety, due to high workload, for example, hand hygiene as an aspect of care left undone.40–42
Changing processes to improve hand hygiene must, therefore, not only start at the individual level, but also
tackle systemic problems at the meso and macro levels together with nursing professionals to create
conditions under which hand hygiene can be implemented appropriately.43
Previous theoretical analysis has shown that the design and characteristics of tracking technologies in
nursing have a tendency to disrespect or even suppress autonomy in favour of control.36 Other empirical
studies on nurses’ attitudes confirm this theoretical perspective.44
Hand hygiene tracking systems can be classified as a persuasive technology and, as such, as a
nudging instrument.45 Studies have shown that hand hygiene tracking systems are effective in improv-
ing the behaviour intended, in this case, adherence to hand hygiene.46 This can justify an intervention
in the autonomy of the user, as it is a nudging strategy that promotes autonomy in accordance with
the professional ethical goals to promote the patients’ beneficence and to avoid harm. They ‘may
make it easier for the subject to act in line with her hierarchy of volitions’47 (p. 503), which would
mean, in this context, performing a thorough ‘individualised’ versus ‘standardized’ hand hygiene in
situations where indicated. As a result, the hand hygiene tracking systems ‘help her [the nudgee] to
choose according to her own conception of the good in situations where she would have previously
done otherwise. In these instances choice architecture increases instances of authentic behaviour, thus
promoting personal autonomy’47 (p. 503).
The study’s main limitation concerns the fact that the results of the ethical sub-analysis need to be
interpreted and discussed regarding the data assessment through a questionnaire instead of focus groups.
Due to the nature of a questionnaire, the possible depth in data compared to focus group interviews was not
achievable. This resulted in a complex, uneconomic questionnaire leading to a small sample size (n ¼ 15
participants). This possibly led to a lack of comprehensiveness of the ethical assessment. Nevertheless, this
approach was inevitable due to safety concerns. Both (1) the need for the ethical evaluation of tracking
technology in infection prevention and control and (2) minimising the workload of nurses were essential in
the current pandemic. The use of a questionnaire, therefore, seemed acceptable. The descriptive approach
was appropriate in this study as a first step; however, further research with experimental designs is needed.
Conclusion
Study results indicate a vast potential for improving the implementation process of hand hygiene technol-
ogies. In this study, ethical concerns did not seem to be a relevant barrier for the successful implementation
of hand hygiene technologies. The present study shows that, especially in nursing ethics, it is necessary to
reach a deeper understanding of the challenges, which can be achieved especially through qualitative data.
Otherwise, it remains unclear, how the interviewees interpret core concepts, such as autonomy. However,
Meng et al. 9
Meng et al. 445
since the concrete individual perceptions can sometimes deviate considerably from the theoretical assump-
tions, a thorough knowledge in the specific context is necessary to determine their impact and understand
with respect to implementation processes obstacles and facilitators in nursing practice.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or
publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: We acknowledge the funding of the Federal Ministry for Education and Research
(Joint Project Number V4IIP041; PräBea 16SV7749).
ORCID iDs
Michael Meng https://orcid.org/0000-0002-4049-7846
Anna-Henrikje Seidlein https://orcid.org/0000-0002-7690-567X
Note
1. In contrast to the majority of publications on this topic, the authors refer to the term ‘adherence’ instead of
‘compliance’. This is especially due to the fact that the term stresses the knowledge and agreement of nurses with
guidelines for good practice concerning hand hygiene. Adherence emphasises nurses’ active professional role
rather than viewing them as persons who are expected to do what they are told. However, when citing other
studies, the original wording of the authors is used.
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