Our findings revealed a lower adherence rate than that recommended in all professional categories, moments analyzed, days of the week, sectors and work shifts observed in the different scenarios of professional practice. Thus, we verified that adherence to HH is affected, or is influenced by the physical structure, the use of gloves by the procedure, type of labor relationship and perception of the patient's safety.
Different factors may be related to the low adherence to said safety behavior. Among them, health services with inadequate physical structure, including poorly located sinks9,16, dispensers of inoperative and out-of-reach alcoholic solutions3, use of gloves17-18, lack of training, among others.4,11
It was verified that the participation in training offered by the institution did not influence in the increase of the adhesion to HH. It is believed that this fact may have occurred due to the nature of the training offered, in a traditional and little problematizing way. Recent studies have shown that the use of training in this modality, based only on the transmission of knowledge and not protagonism of the participants, had little impact on adherence to Standard Precautions and HH.19,20
Thus, WHO recommends that health institutions invest in multimodal strategies to improve HH with dynamic educational actions, based on permanent health education and multimodal strategy to improve HH in order to foster learning in the work environment through link between theory and practice.11 In addition, dynamic methods that promote the interaction between professionals through wheels and talk, workshops and demonstration of HH practice have been more effective in increasing adherence to HH.21,6,7
The infrastructure for hand hygiene practice in the institution of the present study is deficient. The lack of necessary inputs for HH, such as liquid soap, paper towel or alcohol solution, was visualized. The difficulty of access to sinks and dispensers, as well as installation in ergonomically incorrect points can hinder adherence to HH.9
A cross-sectional study conducted in Canada showed that the greater distance between the patient's site and the sink is associated with a decrease in HH adhesion. Each additional meter, which should be covered by the health professional to reach a sink, decreased the probability of hand washing by approximately 10%.9 Similarly, a study in the pediatric and neonatal ICU in the United Kingdon found that, as the visibility of the sink increased, the number of HH actions also increased statistically (p <0.05).22
In our study, although alcoholic preparations were made available in the hospital units in the form of dispensers on the walls, they were not always available at the service centers. According to WHO, the point of care is the place where three elements meet: the patient, the health professional and the assistance or treatment involving the contact with the patient or its surroundings.3,11
In this sense, it is important to consider that studies that implemented the WHO multimodal strategy and achieved satisfactory adherence rates over time invested primarily in infrastructure, which is the first element of this strategy.11 Thus, the support and involvement of the leadership of the institution, as well as a multidimensional approach, are fundamental to reach the significant improvement of HH.10
The institution of the present study did not have, until the moment of the collection of data, posters about the MH technique at the points of care. WHO posters act as an educational element and have the primary function of alerting professionals to HH. As an essential element in raising adherence rates, the illustrative posters allied to periodic training on HH have been recommended in the main guidelines on the theme. 11,23,24
The use of gloves was observed in parallel with a negative action of HH in the five moments recommended by the WHO. It is important to highlight that the inadequate use of gloves obtained a great impact for adherence to HH and was perceived as one of the factors that can hinder this practice by health professionals, with emphasis on the indications "before performing aseptic procedures" and "after risk of exposure to body fluids. "
Our findings showed that gloves were frequently used by professionals before performing aseptic procedures and without prior hand hygiene. At the time "after exposure to body fluids", professionals removed their gloves and did not sanitize their hands immediately after withdrawal, as recommended by WHO. The same situation is reported in other countries according to previous studies.17,18
It should be noted that in addition to the risks of dissemination of IRAS to patients, their environment and care, one of the great risks associated with this low adhesion to HH is the contamination of glove boxes, making them an environmental reservoir of pathogens. 25
In this research, the sector with the highest adhesion to gloves was the adult ICU (91%) and this result may be related to the low adherence to HH found in this sector (44%). These findings are in line with other research that attributed the use of gloves as one of the major risk factors for noncompliance with hand hygiene.17,18,26
Regarding the perception of the patient's safety climate, SAQ scores were low for all domains evaluated, corroborating with studies conducted in other Brazilian states that obtained total scores below 75.27-29
It is worth noting the lower scores perceived by professionals in the domain "Perception of unit and hospital management". It is emphasized that this domain is a fundamental factor for patient safety, since it reflects the agreement of the professional regarding the actions and involvement of the management or the administration of the hospital and the units. In this way, creating a favorable working environment that is conducive to open dialogue about errors as well as a collaborative and non-punitive environment are actions of hospital and unit management that can have a positive impact on patient safety.30
The perception of a security climate varied according to different work regimes. Resident physicians and contracted professionals had higher averages when compared to statutory ones (p <0.05).
This finding may be associated with the shorter service time of these professionals in the institution, since the opposite situation was seen in another similar study in which professionals with more time of service in the institution perceived better the individual and collective competences regarding the commitment of the hospital with the security issues.28
In addition, since host servers have little stability due to the adopted (temporary) work regime, they tend to present more positive responses to the security culture because they fear retaliation in the work environment, although the secrecy of the data has been highlighted several times during the study. Similar data were found in the research carried out by Carvalho et al. 28, which verified higher scores for contracted employees when compared to statutory ones.
The correlation between SAQ and adherence to HH in the sectors was positive and moderate, which shows that as the safety climate scores increase, adherence to HH also increases statistically significantly. This result reinforces the importance of the organizational security climate for adherence to HH.
This research has limitations to consider. It is understood as one of them, the data collection performed in only one institution, since it reduces the number of observations and representativeness of professionals. In addition, it is necessary to consider the Hawthorne effect, potentially present during observational studies.31 To minimize such effect, the approach and signature of the terms of consent to participate in the study were performed 6 months prior to the monitoring. In addition, observations were made daily in 20-minute sessions during the morning, afternoon and evening sessions.