Factors influencing hand hygiene speak-up as perceived by nursing students with clinical practice experience: an application of the theory of planned behavior

Hand hygiene is a cornerstone of infection prevention, and speaking up about hand hygiene non-compliance is increasingly emphasized as a key patient safety behavior. Although nursing students are future healthcare professionals, evidence regarding their hand hygiene speak-up behavior remains limited. This study aimed to identify factors influencing hand hygiene speak-up likelihood among nursing students during clinical practice based on the Theory of Planned Behavior. A descriptive cross-sectional design was used. Participants were nursing students with clinical practice experience. Data were collected using validated instruments measuring the clinical learning environment, hand hygiene perception, patient safety culture, hand hygiene speak-up climate, and hand hygiene speak-up. Data were analyzed using descriptive statistics, independent t-tests, Pearson’s correlation coefficients, and multiple regression analysis. Hand hygiene speak-up likelihood showed significant positive correlations with the clinical learning environment (r = 0.276, p < 0.001), hand hygiene perception (r = 0.203, p = 0.012), patient safety culture (r = 0.261, p = 0.001), and the hand hygiene speak-up climate (r = 0.346, p < 0.001). Multiple regression analysis revealed that the hand hygiene speak-up climate (β = 0.242, p = 0.035) and the duration of hand hygiene education (β = 0.185, p = 0.021) were significant predictors of hand hygiene speak-up likelihood, jointly explaining 13.1% of the variance. In this study, hand hygiene speak-up was operationalised as the likelihood of speaking up in hypothetical hand hygiene non-compliance scenarios, rather than observed or self-reported actual speaking-up behaviour in clinical practice. Although statistically significant relationships were identified, the correlations among the variables were generally weak and the regression model explained a relatively small proportion of variance in hand hygiene speak-up behavior. Therefore, the findings should be interpreted with caution. The findings of this study indicate that nursing students’ hand hygiene speak-up likelihood is significantly associated with the clinical learning environment, hand hygiene perception, patient safety culture, and the hand hygiene speak-up climate, with the speak-up climate and the duration of hand hygiene education emerging as key influencing factors. These results suggest that hand hygiene speak-up among nursing students represents a multidimensional behavioural intention, shaped not only by individual perceptions but also by educational exposure and the organisational context of clinical training. Accordingly, fostering a psychologically safe clinical learning environment and providing repeated, simulation-based hand hygiene education that reflects real clinical situations are essential for strengthening nursing students’ willingness and confidence to speak up for patient safety. However, because hand hygiene speak-up in this study reflects an intentional propensity rather than actual behaviour, the findings should be interpreted as foundational evidence for educational and environmental strategies to promote speaking up, rather than as direct indicators of speaking-up performance in clinical practice. Not applicable. Nursing students’ likelihood of speaking up about hand hygiene non-compliance was significantly associated with a supportive hand hygiene speak-up climate during clinical practice. Longer duration of hand hygiene education exerted a positive influence on nursing students’ willingness to speak up, highlighting the importance of sufficient educational exposure. Hand hygiene speak-up likelihood showed positive correlations with the clinical learning environment, hand hygiene awareness, and patient safety culture. These findings underscore the importance of fostering a psychologically safe clinical learning environment and integrating experiential, simulation-based hand hygiene education into nursing curricula to promote proactive patient safety behaviors among nursing students.