Psychological Factors of Hand Hygiene

Presented by:Dr. Maryanne McGuckin, FSHEA

Disclosure Currently, McGuckin Methods International has a

consulting agreement for clinical trials with Hand-In-Scan.

No material presented will be related to Hand-in-Scan products.

McGuckin Methods International Mission: Pioneering effective methods for safe

healthcare delivery through research, education and advocacy.

Academic Career: Faculty of the University of Pennsylvania

Psychological Factors: DEFINEDPsychological factors refer to:

1. Thoughts 2. Feelings 3. Cognitive characteristics that affect the attitude,

behavior and functions of the human mind.

HCWs, Patients and Consumers have different factors that affect HHC.

Dr. McGuckin’s Psychology on Hand Hygiene

Be Passionate. Be Persuasive.

Learning Objectives

Healthcare Associated Infections (HAIs) Cost: Total annual costs for the 5 major infections: $9.8

billion JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46.

Cost when including social impact: $96-147 billion J Med Econ. 2013 Dec;16(12):1399-404.

Burden: 1 out of every 25 patients in U.S. hospitals affected by an HAI

N Engl J Med. 2014 Mar 27;370(13):1198-208 WHO Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least

one health care-associated infection

Recent studies conducted in Europe reported hospital-wide prevalence rates of patients affected by HAIs ranging from 4.6% to 9.3% (2013).

Compliance in U.S.: MulticenterDespite overwhelming evidence that hand hygiene programs reduce the spread of HAIs, compliance is at or below 50% - even after

consistent education, measurement and feedback.

MonthICU

Compliance

Non-ICU Complianc

eBaseline 26% 36%

1 29% 36%2 29% 39%3 31% 39%4 37% 44%5 37% 46%6 35% 45%7 39% 49%8 41% 49%9 35% 48%

10 39% 47%11 39% 48%12 36% 51%  p = 0.0119  p < 0.0001 

McGuckin M, Waterman R, Govednik J. Hand Hygiene Compliance in US. A Multicenter Evaluation using Product Volume Measurement and Feedback. American Journal of Medical Quality 24(3) 205-213 2009

What we know about HH ProgramsCompliance programs must be MULTIMODAL:

Product at point of care

Education Intervention Measurement & Feedback Patient Participation

However, achieving significant and sustained improvement has been challenging.

HCW Psychological Factors:Spontaneous or Determinative

Dr’s Lounge

How do HCWs Think?We were trained to break down concepts into parts...but in complex

systems – like hand hygiene and health care delivery Relationships between parts are far greater than the parts alone

. Carla J. Alvarado, PhD Research Scientist Emerita University of Wisconsin-Madison

HCWs Psychology and HHApplying psychological frameworks of behaviour change to improve healthcare worker hand hygiene: a systematic review

Goal: To identify studies that used psychological theories of behaviour change to increase or predict hand hygiene compliance among HCWs.

Theories: 1) Positive reinforcement2) Change theory 3) Theory of planned behaviour4) Transtheoretical model5) Prediction studies based on the theory of planned behaviour, the transtheoretical model, and TDF

J.A. Srigley , *, K. Corace b, D.P. Hargadon D. Yu a, T. MacDonald , L. Fabrigar G. Garber. Ontario JHI 2016.

ConclusionNo theory produced significant and sustained

increases Studies have used models that are best suited to explain deliberative

behaviours. Hand hygiene is a repetitive, automatic behaviour and more of a

habit. Hand hygiene is a spontaneous behaviour involving non-thoughtful

behavioural responses. Habit theories stress the importance of establishing strong automatic

associations between performance of a behaviour and cues at the time the behaviour is initially started and that these cues are present in the environment where the behaviour will later be performed What might these clues be???

Always there and always replaced.Provide education at time of performance.

Factors That Influence Physician Hand Hygiene ComplianceTDF: 42 physician interviews, 14 domains 9 domains reported, based on Pittet work: Knowledge Skills Beliefs about capabilities Beliefs about consequences Goals Memory Attention and decision processes Environmental context and resources Social influences

“Priming” Hand Hygiene Compliance in Clinical EnvironmentsPriming in terms of psychology refers to the effects of some event or action on subsequent associated response

Control group - 404 Two phases: olfactory (160) and visual (124)Control group: 15% HHCOlfactory: 46% HHCVisual: Male eyes: 33%; Female:10% HHC Top: Female Bottom: Male

D., Vlaev, I., Everett-Thomas, R., Fitzpatrick, M., Darzi, A., & Birnbach, D. J. (2015, July 27). “Priming” Hand Hygiene Compliance in Clinical Environments. Health Psychology.Advance online publication

Theory of Obedience and Role ModelingVoice Prompts: ICU

“We want 100% HH Compliance in our ICU.”

“Remember handwashing before and after patient contact.”

“Gloves do not replace hand hygiene.”

McGuckin M. The Effect of Random Voice Hand Hygiene Messages Delivered By Medical, Nursing and Infection Control Staff On Hand Hygiene Compliance In Intensive Care. AJIC. 2006

Significant increase in hand sanitizer by HCW and visitor

It’s Not All About Me: Motivating Hand Hygiene Among Health Care Professionals by Focusing on Patients: Psychological Science 22(12) 1494–1499Personal Safety versus Patient Safety: Persuasion Theory Using Reminders of Patient Consequences HCW sign, “Hand hygiene prevents you from catching

diseases.” The patient-consequences sign, “Hand hygiene prevents

patients from catching diseases.” The control sign, which was developed by hospital managers,

“Gel in, wash out.” The patient-consequences sign produced an increase of more than 45% in the amount of hand-hygiene product used per dispenser and an increase of more than 10% in HHC.

Grant and Hoffman Management Department, The Wharton School, University of Pennsylvania, and 2Kenan-Flagler Business School, University of North Carolina at Chapel Hill

Patient Psychological Factors

“Patients should be sure that any Physician, Nurse,

Therapist, has washed his/her hands before

touching them.”

McGuckin, M., Medical World News, 2-15-82

27 Years Later!!!!"A process in which patients understand their role, are given the knowledge and

skills by their health-care provider to perform a task in an environment that

recognizes community and cultural differences and encourages patient

participation.”WHO Guidelines on Hand Hygiene in Health Care (2009)

Health empowerment emphasizes facilitating one’s awareness of the ability to participate knowingly in

health and health care decisions.

Evidence That Empowerment Works

Acute care - McGuckin, et al, AJIC 1999;27:309-14 McGuckin, et al, JOIC 2001;48:222-227

Acute Care Oxford, UK - McGuckin M. The Journal of Hospital Infection, 48:222-227 2001.

LTC - McGuckin, et al, The Director 2004,Vol 12;(1):14-17

Rehabilitation - McGuckin, et al, Am J Infect Control 2004;32:235-8

ICU - McGuckin, et al, Am J Infect Control Dec 2006

PIYC Empowerment Model Evaluation 1997-2006Year Location Source Impact1997 US, multicenter McGuckin et. al. Patient Education Model for Increasing Handwashing Compliance. Am J Infect

Control 1999.+ 34% HH/bd

1998 Oxford, UK McGuckin et. al. Evaluation of Patient Empowering Hand Hygiene Programme in UK. J Hosp Infec 2001.

+ 40% HH/bd

1999 Norway 5 hospitals + 40% HH/bd2000 Denmark 5 hospitals + 35% HH/bd2001 Netherlands 2 hospitals + 50% HH/bd2001-2 Germany 20 hospitals + 40% HH/bd2002 Switzerland 2 hospitals + 45% HH/bd2003 US

rehabilitation hospital.

McGuckin et. al. Evaluation of a Patient Education Model for Increasing Hand Hygiene Compliance in an In-Patient Rehabilitation Unit. Am J Infect Control 2004.

+ 56% HH/bd

2005 Long Term Care McGuckin, et. al. Validation of a Comprehensive Infection Control Program in LTC The Director 2004.

+ 52% HH/bd

2005 US McGuckin et al. Consumer attitudes about health care-acquired infections and hand hygiene. Am J Med Qual. 2006.

80% would ask

2006 ICU McGuckin, et. al. The Effect of Random Voice Hand Hygiene Messages Delivered by Medical, Nursing, and Infection Control Staff on Hand Hygiene Compliance in Intensive Care Am J Infect Control 2006.

+ 100% sanitizer use

HH/bd = Hand Hygiene occurrences per patient bed day

DO PATIENTS WANT TO BE EMPOWERED?National Telephone Survey – U.S.

80% (4/5) respondents said they would ask their HCW to wash hands if encouraged by staff

52% respondents saw HCW put on gloves rather than practice HH

McGuckin M, et al. Consumer Attitudes About Healthcare-Acquired Infections and Hand Hygiene. Amer Journal of Med Quality. 21:1-5, 2006

2007 SurveyIf your doctor, nurse or other person providing healthcare to you, DID NOT ASK or invite you to remind them to wash/sanitize their hands before examining you, would you feel comfortable asking them to wash/sanitize their hands?

If your doctor, nurse or other person providing healthcare to you ASKED or invited you to remind them to wash/sanitize their hands before examining you, would you feel able to do this?

If you saw your doctor or nurse taking care of the patient next to you and then coming to you without washing or sanitizing their hands, would you ask them to do so?

YES

0

10

20

30

40

50

60

70

80

90

100

Overall USA Canada Overall USA Canada Overall USA Canada

58.3%

69.8%

47.8%

86.9%94.9%

84.8% 80.6%90.5%

65.2%

ConclusionMost patients believe that they should be involved in hand hygiene

29%

71%

Patients should not be involved Patients should be involved

Source: National Patient Safety Agency

Willingness: Patients want Empowerment!

These show intention, not action. Missing link: HCW explicit permission to ask

57%43%

1989:Pay for IC infor-

mation1

Yes No

70%

30%

1999-2005Ask about HH2

Yes No

71%

29%

2005:Involved in HH3

Yes No

80%

20%

2006:Ask if given permission4

Yes No

Sources (left to right): 1) P.J. Miller, B.M. Farr. Survey of patients’ knowledge of nosocomial infections. Am J Infect Control 1989;17:31-4.; 2) McGuckin various studies, 3) National Health Service. National Patient Safety Guide Cleanyourhands campaign supporting resource 28 – Staff Guide to Patient Involvement, 4) McGuckin M, Waterman R, Shubin A. Consumer attitudes about health care-acquired infections and hand hygiene. Am J Med Qual. 2006 Sep-Oct;21(5):342-6.

Evidence for HCW Explicit PermissionStudy origin

Patient believes he/she should be

involved

Patient would ask about hand hygiene

Would Ask if HCW permission to patient

England and Wales NPSA (2004)1 71% 26% Not measured (N/M)

Ontario (Canada)2 32% 42% N/M

USA consumer survey3 N/M N/M 80%

USA web survey4 N/M 60% N/MWorld Health Organization survey5 N/M 52% 86%

UK6 79% N/M N/M

USA7 91% 45% N/M

UK8 Significant increase

Switzerland9 N/M 33% 81%

Australia10 90% 40% N/M

HCW Explicit Permission to PatientsHow useful do you think the following interventions would be in encouraging hand hygiene? Results combined from patients, healthcare workers, and coordinators. (N=1115 participants)

Pittet D, Panesar SS, Wilson K, Longtin Y, Morris T, Allan V, Storr J, Cleary K, Donaldson L. Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study. J Hosp Infect. 2011 Apr;77(4):299-303.

Ask Me to Sanitize or Wash My Hands

THE PSYCHOLOGICAL THEORIES OF INFLUENCE AND PERSUASION

http://changingminds.org/explanations/theories/a_clusters.htm

A Review of Electronic Hand Hygiene Monitoring: Considerations for Hospital Management in Data Collection, Healthcare Worker Supervision, and Patient Perception Patient Perception on Electronic Devices: not much research. One study: Michaelse, Sanders, Zimmer, and Bump (2013)

Flashing alerts worn by HCW versus brochure on admission on HAIs (93% liked alert versus 7% brochure)

BUT90% would not seek care from doctor that did not

perform HH and 60% would not go to that hospital.

McGuckin et al. Journal of HealtHcare ManageMent 60:5 SepteMber/october 2015

Consumer Awareness

IF ONLY I KNEW

Consumer perceptions of healthcare associated infection and hand hygiene- a global survey

Claire Kilpatrick, Director S3 GlobalConsultant to the World Health Organisation@safesafersafest @claireekt @WHO

Dr. Maryanne McGuckinMcGuckin Methods International www.mcguckinmethods.com @drmcguckinHosted by Jules StorrWorld Health Organization

Sponsored by WHO Patient Safety Challenge Clean

Care is Safer Care

www.webbertraining.com

Consumers and Health Care If consumers make decisions about their health care choices, would they consider hand hygiene/infection standards as part of this decision making?

A telephone survey was conducted: N=1001 Ireland (n=250), India (n=251), Mexico (n=251) and Hong Kong (n=249), were surveyed The period of study was October 22-29, 2014

The majority of respondents surveyed believe that health workers clean their hands at the right times when treating or caring for patients. This belief is highest among those in Hong Kong, followed by India.

A1: Do you think that health workers (e.g. nurses and doctors) in hospitals and other settings (for example, clinics) clean their hands at the right times when treating/caring for patients? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

The majority of those who believe health care workers clean their hands at the right time believe they do so all of the time, except among those in Ireland. In Ireland, the majority believe it’s just some of the time.

A2: Do you think that health workers are cleaning their hands at the right time…? Base=Think health workers clean their hands at the right time (Hong Kong=200, India=167, Ireland=133, Mexico=143)

Those in India are most likely to have asked a health worker about clean hands with respect to a visit or treatment they were receiving. Those in Mexico are second most likely to have asked, followed by those in Hong Kong. Very few in Ireland have asked.

A4: Have you ever asked an individual physician (doctor), nurse or other health worker, or a health care organization (e.g. hospital or clinic) any questions about this subject of clean hands with respect to a hospital/clinic visit or treatment you were receiving? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

Responses to questions about health workers cleaning their hands at the right time were based on respondents’ own personal experience for at least seven out of ten. Significantly fewer responses were based on information from friends and relatives, and few were based on media.

A3: Were your answers to the previous questions based on…? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

When asked what they think happens if the hands of health workers are not cleaned at the right time before touching patients, more than four in five said that germs are spread to patients. Half said the health worker might get sick. Those in Hong Kong are least to think patients might be seriously harmed or even die, germs may spread to family members, or infections are passed on to patients.

A5: What do you think happens if the hands of nurses/doctors/other health workers are not cleaned at the right time before touching patients? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

AWARENESS, ENGAGEMENT AND INTENT

How the Consumer Uses These Actions Demographic Characteristics of Consumer

Public Reporting of Health Care–Associated Infection Rates Maryanne McGuckin, DrScEd, FSHEA, John Govednik, MS, David Hyman, JD, MD, Bernard Black, JD American Journal of Medical Quality Vol 29, Issue 1, pp. 83 – 85: July-23-2013

Consumer Results (Cont’d)

1P = 0.0248 2P=0.0011 3P=0.0002 4P = 0.0143 5P = 0.0183 6P = 0.8620

Consumer Results (Cont’d)Awareness Engagement Intention

Educ High Sch 32% 8% 58%College 40% 12% 50%Post Grad 47% 18% 47%

More educ more aware1

More educ more engaged2

More educ less intent3

Inc <$25,000 30% 9% 60%$25-59,999 39% 12% 55%$60-99,999 41% 12% 48%$100,000+ 46% 16% 43%

More income more aware4

Not significant5 More income less intent6

1P < 0.0001 2P < 0.0001 3P < 0.0001 4P = 0.0007 5P = 0.0928 6P < 0.0001

Consumer Results (Cont’d)

1P=0.0001 2P < 0.0001 3P<0.0001

Persuasive Theory Healthcare workers are empowered

when they educate patients and invite them to ask questions

Patients are empowered by participating in decisions helping to address medical errors

Further reading: McGuckin M, Storr J, Longtin Y, Allegranzi B, Pittet D. Patient empowerment and multimodal hand hygiene promotion: a win-win strategy. Am J Med Qual. 2011 Jan-Feb;26(1):10-7.

A FORM OF COMMUNICATION THAT AIMS AT MESSAGES THAT SUBTLY CHANGE THE ATTITUDE OF THE

RECEIVER.

Steps of Persuasion Process As proposed by Professor Jay Conger, the following are the steps to be

followed in the Persuasion Process:• Step 1: Establish Credibility and Trust in Yourself

• Step 2: Find a Basis of Common Ground• Step 3: Provide Vivid Proof• Step 4: Connect at an Emotional Level

Let us look at each in

detail.

Step 1: Establish Credibility and Trust in YourselfThe first step of the ‘Persuasion Process’ is to establish credibility and trust in yourself in the minds of the audience. You can do this by using your expertise and knowledge in the field that you are speaking about, by building and then appealing to the strong relationships that you share with your audience, by carefully listening to others and their opinions and by using your history of good judgement to appeal to each person’s individual personality.

Step 2: Find a Basis of Common GroundIn this step you must highlight the advantages that the people you are trying to persuade would experience. In order to do that, you must thoroughly understand the challenges that your audience faces, and what they most care about. A common ground cannot be an idea or solution that is good for its own sake.

Step 3: Provide Vivid ProofThis step involves presenting your audience with vivid or clear proofs to support your statements and opinion. You can use logic and facts to support your statements, using imagery and metaphors to help other person compare and understand your opinions. You can use stories and examples to help other person associate with your ideas and feelings. You may use numbers to prove your statements by presenting spreadsheets to support your statements.

Step 4: Connect at an Emotional LevelThis step involves connecting with the other person at an emotional level. You should understand the tangents or aspects to the person’s personality. You should show empathy and your respect for their feelings and opinions. You should show your commitment, honesty and dedication. In order to connect at an emotional level, you should have a high degree of self-awareness so that you can understand your own emotions as well as the other person’s emotions.

Conclusion: “I Never Thought of it That Way!” It is human nature not to believe something is

possible if it doesn’t fit into the current view. Our current view on HH compliance has become

focused on technology and trying to show what does not work rather than focusing on human nature.

Beyond Empowerment: Patients, Paradiggms, and Social Moveements. PSQH, Vol 13, Issue 2 April 2016

Are we Overthinking HHC?Two-step process: Quantitative and Qualitative

1.Quantitiative: Get HCWs to the sink/product at the right times THEN 2 .Qualitative: Educate and monitor technique.

Hand Hygiene Procedures

HAND HYGIENE!

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