Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

Sub-Optimal Hand Hygiene Campaign in Hospitals: Why Health Care Workers Refuse to Put on Gloves and Wash Dirty Hands – Yue Zhang

Introduction
Health care workers (HCWs) are those people who provide the hands-on care and personal assistance received by patients. They are doctors, nurses, medical students, and others (physiotherapist/care-assistants/dietitian). Cross-transmission of microorganisms on healthcare workers' hands is the main route of spreading multi-resistant organisms and has been recognized as a substantial contributor to outbreaks of infection (1, 2,3). This cross-transmission of resistant organisms endangers patients and is a major challenge for hospitals. Evidence supports the belief that improved hand hygiene can reduce healthcare associated infection rates (4,5,6). HCW must wash hands every time by using of alcohol-based gel or soap and water immediately before and after patient contact. Patient colonized with a resistant organism should be isolated. HCW must wear gloves when entering room of patient on contact precautions whether or not direct contact is anticipated, and removed them immediately when they leave the rooms.

Research efforts, money and other resources have been used to improve health care handwashing and glove use. Hand hygiene promotion is a major challenge worldwide. CDC published the first formal written guidelines on hand hygiene in hospitals in 1975 (1). It has revised the guidelines in 1985 and 2002 in the hope to make the hand washing practices more practical for healthcare workers. Current handwashing guidelines have focused on the accessibility of equipment, hand-rubbing solution, and the amount of patients HCW have. Even with all of these changes there is only 40% compliance, far from the 100% compliance. (1, 7,8,9,10,11).

I looked at the handwashing campaign in hospitals and focused on Boston Medical Center compliance to these guidelines. Boston Medical Center (BMC), a 581 bed teaching hospital where at least 10% of patients are known to be colonized with a resistant organism. The availability of alcohol hand rub and gloves is almost perfect, while the compliance with handwashing and glove use are only 56% and 44%, respectively. Poor compliance with hand hygiene was not explained by lack of accessibility to alcohol hand rub or gloves. Given the severity of infections due to multidrug-resistant organisms and the prevalence of immunodeficient patients, the poor hand hygiene of HCWs makes one wonder where is the safer place to stay—at home or at the hospital.

Failure to emphasize social norm, group and modeling effects
Most of the interventions to improve hand hygiene compliance in hospital care workers focus on individual factors. Theory of Planned Behavior (TPB) is most commonly used in HCW’s hygiene interventions (9,11,12,13,14,15). TPB is based on three major ideas -- perceived norms, attitudes, and self efficacy (16,17,18). This theory has made some limited contributions to the hand hygiene campaign. However, Theory of Planned Behavior is still a model at an individual level. It remains focused on the individual’s attitudes and perceptions. This is a huge limitation since the individual’s perception of social norms tends to be unstable and may not accurately represent “true” social norms. For example, a nurse might believe that it is her option to follow (or violate) a particular rule or regulation because such variable behavior does not impact her acceptance in her peer group. Her ideas towards the regulation might be unstable and change based on her work load, mood, or convenience. The instability of these individual factors may result in unstable compliance with her hand washing and glove use. In addition, the individual adherence to hand hygiene policies varies dramatically from one person to the next. In contrast, the “true” social norm inculcates habits in everyone and does not require an individual (doctor or nurse) to think about the action before it is performed. If there is any breach in behavior, the individual will feel embarrassed and quite likely the violation will be noticed and corrected by others as well.

Patients, but not HCWs, are being punished for HCWs’ undesired behavior
The Hand Hygiene Campaign focuses on changing the individual behaviors of the HCWs, however the outcome of their compliance effects patients quality of care, risk of infections, and medical cost. Therefore, the efficacy of a hand hygiene campaign in modifying HCW behavior is not hard to guess. This year, a study from the Cedars-Sinai Medical Center, presented at the 45th Annual Meeting of the Infectious Diseases Society of America, showed strong evidence that suspension of privileges of a single noncompliant HCW really changed group behavior. Doctors in this hospital were the most recalcitrant to change behavior despite education and leadership involvement. However, once one physician’s privileges had been suspended as a result of poor compliance with hand hygiene, the compliance among the remainder of the staff improved immediately, almost to the hospital target of 90% (19). This result is not surprising at all. This study results indicate that to change HCW hygiene behaviors, there must be immediate socially known consequence to individuals, not to hospital institutions, that HCW can understand and want to change behavior.

Reasoning about hand hygiene on patient safety does not necessarily lead to high adherence
HCW are well educated workers and they realize the severe consequences to their patients from healthcare associated infection, but do not correlate these outcomes with their own noncompliant behavior. The perception that hand hygiene is effective at preventing infections was ranked highly in most of the studies, even though compliance with hand hygiene was low (9,15). The low correlation between self-reported and observed compliance is another piece of evidence (12). This is one explanation for why many great attempts to educate were not as successful as expected. In fact, some HCWs were offended by the education programs and refused to participate in hand hygiene campaigns.

The question now becomes whether or not it is true that promoting hand hygiene for the sake of patient safety necessarily leads to high adherence. The answer is obviously NO from all of the data. Good intention does not necessarily lead to good behavior. This has been proved again and again in all kinds of studies and research. The hand hygiene campaign has failed to recognize this fact. This is due to the imperfect models the hand hygiene campaign mainly relied on, specifically the Theory of Planned Behavior and Health Belief models (9,12,14,15). The key idea in these models reasons that intention leads to behavior. As a matter of fact, this is the most fragile link and is easily broken. Education and guilt were the weapons used in this campaign, but they are still not powerful enough because of the disconnect between intent and action.

Implications
One might become quite confused after thinking about social norms for hand hygiene on the medical wards. What are the social norms when there is a compliance of only around 50%? Do half of the people wash their hands and use gloves as required while the other half do not? Do all of the HCW choose to wash their hands and use gloves as required only half of the time? Does this mean there are no social norms among this group? Wrong! Firstly, rates of compliance are different from hospital to hospital. In hospitals with a long tradition of hand hygiene campaigns, social norms are strongly in favor of hand hygiene (9). However, adherence with recommended hand hygiene is lower in the hospitals with less administrative enforcement. Secondly, according to multiple studies and CDC reports, when we examine the compliance among different groups of HCWs, adherence varies markedly across medical specialties (1, 7). Most of the studies found that nurses have better compliance compared with doctors and other HCWs (1,20). From my research, I found an average overall glove use of 46% among HCW, with 53%, 37%, 50%, and 40% for doctors, medical students, nurse, and others, respectively. Handwashing was observed an overall average of 56% of the time among HCW, with 84%, 68%, 59%, and 22% for doctors, medical students, nurses, and others respectively. These data show that doctors at BMC do a fairly good job compared with other groups, even though their performance is still far from the goal of 100% compliance. All of these data imply that there are different social norms and group effects. They have differing impacts on different groups of HCWs. In addition, several studies have shown that social pressure from patients, superiors, colleagues, and the person perceived to be the most influential have a huge impact on HCW hand hygiene (2). This finding suggests that we should focus on the group or hospital level instead of the individual level to effect uniform habitual behavior.

The important impact of role models has been shown with students, whose adherence was strongly influenced by their mentors’ attitude at the bedside (9,15,20,21,22). My observations at BMC also showed that medical students’ hand hygiene habits are highly predicted by those of their teachers. The hand hygiene campaign failed to foresee the importance of this group of young people. As a matter of fact, the current medical and nursing students will soon become the dominant figures in the health care field; and the behaviors they learn today could last for 30 to 40 years or even longer over the span of their careers. The foundation of their behavior and norms in their practice should be one of the main targets of the hand hygiene campaign.

Conclusion
Hand hygiene is recognized as the primary determinant of the incidence of healthcare-associated infection and the leading measure to prevent cross-transmission of multidrug-resistant organisms. Health care worker compliance with hand hygiene guidelines is sub-optimal. Many efforts have been made to address this problem but with poor success. Multiple behavioral theories have been used in this campaign, also with slim success. Multifaceted interventions have a better chance of success based on several recent studies ( 6,14,20,23). However, there is not a single published study that has shown consistent and high quality compliance despite all of the efforts and multiple behavioral models.

Social Expectation Theory has shown great success in changing social norms such as smoking bans in restaurants. It might be a good theory to be implemented in the hand hygiene campaign as well. Hand hygiene should not be a personal choice, but rather a social norm. Once the social norm changes, the individual behavior will change. The tricky question becomes how do you change social norms? As mentioned above, strict regulation, legislation, or even suspension of a license might lead to a fundamental change. Real consequences to HCWs, instead of patients, will improve compliance. It might seem extreme for certain people to use an iron fist, but given the severity of outcomes and complexity of the hand hygiene campaign, it is time for action: change the social norm among health care workers and protect patients from HCWs undesired behavior.

REFERENCES
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