Design and methods

We collected the demographic data during the first on-site visit in each RCH unit included in this study. The demographic data included the following: number of residents, number of healthcare workers, availability of alcohol-based hand rubs (ABHR), and availability of washing facilities. The observations of ICP include hand hygiene, use of gloves, use of personal protective equipment (PPE), respiratory hygiene, handling of sharp equipment, decontamination of equipment, waste management, and environmental cleaning [13, 14, 19].

We conducted an observational study to observe ICP among healthcare workers in private and government-subsidized RCHs. In this study, the researcher (as a non-participant observer) was a qualified registered nurse who had been trained and had accumulated experience in patient care. This ensured that the researcher was familiar with ICP. The researcher recorded observations at any time in different shifts (morning or afternoon shifts) every day (from Monday to Sunday) in different units of both the private and subsidized RCHs. This allowed for the collection of comprehensive data on staff behavioral changes in different shifts during the weekdays and weekends [19]. For such consecutive observations done for 2–3 weeks in each RCH, the Hawthorne effect was reduced by desensitizing the healthcare workers to the frequent presence of the observer. Such a method has been suggested elsewhere [20] and is considered more reliable for continuous sampling. The observed healthcare workers were chosen randomly to minimize the selection bias. Once the observed staff was chosen, the researcher did not interrupt the care procedure. As the opportunities occurred, the performances were recorded by using an electronic tool, called the “eRub.” According to the guideline, hand hygiene involved ABHR and the use of soap and water for at least 20 s under the condition of the “five moments for hand hygiene” [21].