“Ask Me If I Have Washed My Hands:” A Critique of Patient-Centered Handwashing Campaigns for Health Care Workers – Christine Zachek
The Centers for Disease Control and Prevention estimate that, in American hospitals alone, hospital acquired infections account for 1.7 million infections and 99,000 deaths each year (1). Handwashing has become widely accepted as one of the most important activities in reducing pathogen transmission in health care settings (2). However, compliance with handwashing standards among physicians and hospital staff is unacceptably low, often with rates less than 40% (3). Recent interventions have focused on increasing patient involvement in protecting against hospital-acquired infections. A typical intervention of this type will ask physicians and nurses to wear a button that reads, “Ask me if I have washed my hands” (4) or a sticker that adheres to a patient’s hospital gown that says, “Did you wash your hands?” (5). Some strategies also recommend incorporating an element of patient education, by placing brochures in patient areas around the hospital emphasizing the importance of handwashing in reducing infection transmission (5-7). Evaluations of these campaigns have reported short-term success (8). However, research methods in this area provide unreliable indicators of health care worker behavior because studies are generally limited by small sample size; narrow scope of investigation; and failure to capture a complete range of health care worker activity (9-10). For reasons argued later in this essay, the long-term successes of these campaigns are dubious as they overlook significant social factors that regulate human behavior at the group level.
These campaigns are fundamentally flawed because they fail to account for significant social factors that inhibit patients from challenging their providers and fail to accurately predict the behaviors of doctors and hospital workers. These interventions narrow in scope as they are dedicated to changing behavior at the individual level by relying on patients to prompt health care workers to take action on a one-to-one basis. Creators of these campaigns frame their initiatives in terms of “empowering” patients to take an active role in their own safety and seem to rely on Albert Bandura’s concept of self-efficacy, or a person’s belief in his or her ability to take action, to motivate patients to act (11). A sticker or a button serves to remind and encourage patients to question their doctor or nurses’ hand hygiene habits, supposedly empowering them with self-efficacy (11). However, these interventions do not incorporate any environmental or contextual variables that are present in Bandura’s complete Social Cognitive Theory (12). The educational materials provided by some interventions are aimed at increasing patients’ perceived severity and perceived susceptibility to hospital-acquired infections. This directly follows the Health Belief Model (HBM), which states that individuals will rationally weigh the costs and benefits of an action and choose whether to perform an action based on this calculation (13-14). By increasing the patients’ perceived severity and perceived susceptibility to infections, this increases the perceived benefit of asking a provider if he or she washed his or her hands. So-called “empowering” patients through campaign materials would reduce the patients’ perceived barriers to performing the action under the HBM. The sticker or button serves a cue, or trigger, for the patient to question the provider about handwashing (14).
It is important to note that these interventions target the patients to ultimately change the behavior of another group – health care providers. The patient will not be completing the action that is the desired outcome (i.e. handwashing). The patients’ questioning will provide a cue to action, or an external event that will motivate the nurse or physician to act (12). The health care worker must ultimately complete the action, and as I will argue later, make it a habit in order to be effective in reducing infection transmission. Because the intervention targets and relies on a secondary group to prompt the group of interest, it allows for more potential missteps in the process to achieve the desired outcome.
While these campaigns purport the well-intentioned goal of increasing patient involvement in their care, a “self-defense” strategy to patient safety is questionable at best (15). These campaigns wrongly put the onus on the patients to ensure their own safety “in an environment over which they have no control” (15, p. 2065). These types of interventions fail to consider crucial group-level variables such as power dynamics; fear of damaging the physician-patient relationship; and lack of habitual action that severely limits the effectiveness of the intervention. These factors make it difficult for patients to follow the advice on the buttons and voice their concerns regarding their providers’ hand washing behavior in the first place, and even if this is accomplished, these interventions do not provide a good long-term strategy to make handwashing behavior a more regular occurrence in hospital settings.
Power Imbalance
Lessons from other public health and social science domains teach us that power differentials between individuals can have a substantial impact on individual behavior. This is evident in condom negotiations where gender-based power differentials in traditional societies lead to lower contraceptive use (16). In these instances, women fear that a husband’s disapproval of contraceptives will lead to loss of affection or divorce (17). In the hospital setting, the provider is in a position of power as patients generally do not possess extensive knowledge of medical sciences. This makes patients ‘abjectly dependent’ on their physicians for information and for treatment (18). Furthermore, patients enter into the hospital when they are sick, scared, and vulnerable. In a fragile mental and physical state, patients may not be able to assert their rights effectively or have the “presence of mind” to ask questions regarding handwashing (4, p.1). In this situation, patients are naturally reluctant to raise any issues that may be viewed as confrontational, such as asking hospital workers if they have washed their hands (4, 20). These interventions fail to consider the ramifications of power differentials in the hospital room, or falsely assume that a button or a sticker will be sufficient to override these imbalances.
The interventions also neglect to account emotional factors, such as the fear experienced by patients in a hospital facility. As mentioned in the contraceptive example, fear is a common emotion associated with power imbalance (17). Here, patients may feel they will not receive adequate treatment if they question their caregivers’ authority or ability to keep them free of infection (4). A study by Judith Lorber, which will be revisited later, found that most patients resented the passivity and submissiveness that characterize a patient’s perceived role in the rigid hospital structure. However, most hospitalized patients felt that this was the proper way to act, and that if they did not “keep Quiet,” their care would suffer as a result (21, p.214). George Annas and Joseph Healey echo, “Because a sick person’s first concern is to regain health, he is willing to give up rights that otherwise would be vigorously asserted” (22, p. 245). Ignoring larger, psychosocial factors that drive human behavior, as these interventions have done, is a significant error.
This power differential is amplified with particular populations such as the elderly, non-English speakers, and patients lacking health insurance. Elderly patients tend to be more passive with doctors as medical paternalism, or the notion that the “doctor knows best” and makes decisions for the patients, is more common among older generations (4, 19, p. 113). Aside from the obvious technical issues that non-English speakers would have reading the buttons and verbalizing a response, disadvantaged populations experience an even greater power differential with their physicians or other hospital staff. A patient lacking health insurance may think a physician is “doing them a favor” by treating their ailments under such circumstances, therefore, would not want to raise any issues that might jeopardize their treatment. Jodie Kliman recounts her personal experience waiting in an emergency room, and demanding an intervention from the hospital staff when her husband’s condition became increasingly severe. Reflecting on this experience, she questions whether she would be a widow today had she been of a different class or racial group and less willing or unable to assert herself in the hospital setting (23). She writes, “Many forms of privilege and power, or lack thereof, contribute to our interactions and beliefs… They permeate what we say, what and whom it silences, what we notice or overlook. They operate for those with privilege, and those without” (23, p. 43). These underlying forces were undoubted not considered in this intervention and leave it substantially lacking, particularly with respect to vulnerable populations.
The Physician-Patient Relationship
Based on the information presented in the previous section, the patient-centered handwashing initiative is likely to remain ineffective as patients are in a weaker position in the power hierarchy of a hospital setting and are therefore unlikely to assert themselves. This section will argue that the “ask me if I have washed my hands” intervention is not only ineffective, but has a negative effect on patient outcomes. The intervention fails to consider the broader aspects concerning the nature of the physician-patient relationship, the emotions involved, and the consequences of damaging it. While this paper uses the term, physician-patient relationship, this dynamic can also be applied to other types of providers and caregivers in the hospital setting.
Although the physician-patient relationship has deep historical roots, legal doctrines have outlined the duties of a physician that arise from the fiduciary (trust) nature of the relationship and presence of information asymmetries (18-19). The physician-patient relationship is more than a business-like transaction or simple exchange of information; it involves trust and compassion to make the patient feel comfortable relaying sensitive information to the physician and engaging in a meaningful discussion regarding treatment options (19). The handwashing intervention damages the physician-patient relationship by creating an atmosphere of confrontation, instead of one based on trust and mutual respect. When these qualities are not present, physicians are unable to obtain truthful and complete information from their patients, and patient care suffers as a consequence. Questioning a physician as to whether he or she washed his or her hands creates a combative relationship from the minute the physician enters the room. This interaction instills emotions of resentment and distrust that damage the physician-patient relationship. The failure of the intervention to consider the importance of the integrity of this relationship and the various emotions involved is a serious oversight.
Furthermore, physician education and training can lead to physicians being resistant to patients questioning their authority. Dr. Bruce Siegel comments that many physicians are taught to “think of themselves as little gods,” and would view a challenge to their handwashing habits from their patients as an affront to their authority and professional ability (4, p. 2). Many physicians might not even wear the buttons if they call these deeply engrained values into question. Physicians could also perceive their patients’ questioning as a threat to their personal or professional freedoms. The theory of psychological reactance states that any message that attempts to change behavior could be perceived as a threat to freedom. The mind reacts to preserve freedom by ignoring the request or performing more of the undesired behavior (24). Applied to this context, physicians might experience psychological reactance to a patient challenge (i.e. asking if the physician washed his or her hands) and refuse to take the suggested action. Anecdotal evidence indicates that physicians wash their hands when asked around 60% of the time, but do so quickly and begrudgingly (4, 8). This limits the quality of handwashing behavior (increasing the potential for pathogen transmission) and could possibly reduce the providers’ inclination to wash their hands in the future if they perceive this campaign as a threat to their freedom. The campaign’s failure to consider psychological reactance, and its potential effects on the quality of handwashing at the patient bedside and future consequences for physician behavior could lead to an increase in hospital infection rates.
As previously mentioned, this intervention does not take into account the emotion of fear experienced by most patients that they will not receive adequate care if they question the behavior of their doctors or nurses. A study by Judith Lorber may substantiate these fears, as it documents the possible consequences for patients who go against established hospital norms. Patients who were viewed by staff as cooperative, stoic, and uncomplaining were labeled “good patients.” Those patients who complained when staff felt it was medically unwarranted, were less submissive and, “did not subscribe to the norm of unquestioning obedience” were labeled “problem patients” (21, p. 217). The study found that patients labeled “problem patients” were more likely to be tranquilized or discharged early (21). The hang hygiene interventions could establish, and even encourage, more patients to become “problem patients” in the eyes of the staff. This damages the cooperative relationship between patients and caregivers, potentially leading to a decline in patient health status.
Habit Formation
The patient-centered handwashing intervention is further limited in its failure to establish staff handwashing behavior as a habitual activity. Evidence from psychology and behavioral science indicates that habitual actions govern a substantial part of daily life. Up to 47% of a person’s activities are conducted every day, usually in the same location (25). This consistency establishes what social scientists call habits or, “behavioral dispositions to repeat well-practiced actions given recurring circumstances” (26, p. 918). Much of our behavior (including handwashing) is regulated by habit, rather than by thoughtful consideration (27). Professional marketers and consumer psychologists know this concept well, and for years have sought manufacture habits by integrating consumer products into daily behavior (28). Advertising techniques use subtle habitual cues to tie products to a behavior. For example, Proctor and Gamble created an advertising campaign for Febreze that tied using the perfume to cleaning a room, something their target audience did daily, and sales soared (29).
The “ask me if I have washed my hands” campaign fails to consider the influence of ritual and habit over frequent behaviors. While doctors and nurses are presumably aware of the importance of handwashing in reducing disease transmission, the high frequency of handwashing behavior leads to a reduced consideration for the reasons for performing the behavior (3). Therefore, subtle cues and regular associations should be established in healthcare facilities to foster habit-formation. The patient-centered campaigns exclusively rely on an overt external cue, i.e. the patient prompt, for the behavior to take place. The sporadic nature of patient questioning fails to establish consistency in the hospital worker’s routine, thereby weakening the habitual nature of the action and likelihood that the action will take place on a regular basis (30).
The campaign is further limited because this interaction takes place at the individual-level, with one-on-one discussions between providers and patients. A more effective strategy, such as the one mentioned in the previous paragraph, would seek to change the behavior of healthcare providers as a group. One potential mechanism by which this might be accomplished would be to create salient associations in the minds of physicians to wash their hands every time they enter a patient’s room. The current campaign makes no attempt to establish linkages between a habitual cue and the provider’s handwashing behavior. These linkages proved to be a useful and successful tool in consumer product advertising, a strategy that is readily adaptable to public health interventions like handwashing (29).
Summary of Limitations
While the incorporation of patients and their families into medical decision-making is a noble purpose, the “ask me if I have washed my hands” strategy is misguided as it puts the responsibility for patient safety on the patients themselves. The patients’ control over the situation is limited, and the campaign does not produce an effective long-term strategy for improvements in hospital infection control. The campaigns fail to consider the inherent power imbalances that occur between patients and their caregivers that contribute to a patient’s reluctance to question hand hygiene habits. The interventions also foster a confrontational physician-patient relationship that can be counterproductive to providing patients with quality care. Since the interventions rely on patients to prompt their providers to wash their hands, providers do not create or maintain habitual handwashing behavior. Simply put: (1) it is unlikely that patients will question their providers in the first place; (2) if they do raise the issue, it may carry negative health consequences; and (3) this is not a viable strategy to produce lasting change.
The failure of these campaigns to consider the larger, group-level variables like power differentials, the importance of provider relationships, and habit formation are their downfall. Their narrow scope and individual focus have limited their effectiveness, and potentially caused declines in quality of care, to the detriment of patient safety in hospital settings.
Reintroducing a Role for Health Care Providers in Handwashing Campaigns
Patient-centered handwashing campaigns for health care workers present a faulty approach to reducing pathogen transmission in healthcare facilities. These interventions are not likely to achieve lasting effects on handwashing rates because they ignore significant social factors that influence both patient and provider behavior. The limitations of these campaigns include a failure to consider the power imbalance between patients and healthcare workers; the importance of preserving the physician-patient relationship; and the necessity of habit formation in handwashing behavior. Recognizing these limitations, this paper will propose a more comprehensive alternative to patient-centered handwashing interventions that addresses these three flaws and establishes long-term habit formation by changing behavior at the group-level.
Counter-Proposal: A Brief Outline
A patient-centered campaign to promote hospital handwashing relies on an ineffective power dynamic to change behavior and damages the physician-patient relationship. To address these two limitations, the frame of the intervention will shift to focus on changing the behavior of providers instead of patients.
Secondly, the patient-centered interventions rely on patients to prompt physician or nurse handwashing. This fails to establish handwashing as a habitual behavior, which is crucial for the long-term effectiveness of a campaign (26, 28). This counter-proposal introduces a three-pronged approach to creating a handwashing habit among providers. First, the intervention changes the hospital environment to make handwashing easier and more accessible. Second, advertising messages are developed to foster associations and cue providers to engage in handwashing activity. Third, the intervention encourages a change in institutional culture by working with top-level officials to make handwashing a priority for the facility. In developing and executing the provider-centered intervention, the reasons healthcare workers commonly cite for not washing their hands are taken into account. These include being too busy, forgetfulness, and skin irritation (31). Peer norms are also considered as they are significant predictors of handwashing behavior (27).
The Three-Pronged Approach
1) Changing the Hospital Environment
In order to make handwashing more convenient, alcohol-based sanitizers are placed in strategic locations in or outside patient rooms. To identify a suitable location for the dispenser, focus groups or observational research will be conducted to determine the activities most providers complete before entering a patient room. For example, hospitals usually keep a chart of patient information outside of the patient’s room. If providers routinely review this information before interacting with a patient, dispensers could be placed on the container that holds the chart as a reminder to sanitize hands. This would cue providers to use the sanitizer and incorporate it into their patient care routine. Multiple locations or distribution methods for hand sanitizer would be tested to determine which is the most effective. These could include dispensers at the patient bedside or individual-sized bottles given to doctors and nurses to keep in their pockets.
2) Advertising Campaign
Prong two of the intervention is the development of campaign messages linking handwashing behavior to habitual actions. First, focus groups will be conducted among different segments of hospital staff to better understand what motivates handwashing behavior and to determine what their core values might be (since protecting patients may not be the primary motivator for handwashing). For example, one series of questions could assess whether caregivers wash their hands because they are afraid of getting an illness from their patients. If this is the case, the advertising message could integrate the patient chart as the environmental cue and ask, “Picking up a chart? Don’t pick up an infection. Be sure to wash your hands before greeting your patients.” The focus groups would also investigate cues hospital workers associate with handwashing. If eating is a common cue, the advertising message could be constructed around cuing food and might read, “Would you eat with those hands? Wash up.” An example of appealing to a core value would be to appeal to a physician’s sense of authority with the message “Take charge of handwashing” in the campaign materials.
To assess the most effective campaign medium, the intervention team would probe the focus groups on ways they gather and receive information. Focus groups could be asked to identify which magazines, medical or nursing journals, and newspapers they read. Providers could also be asked if they would watch a video clip emailed to the hospital listserv, or if posters placed in the staff lounges would be readily noticed.
3) Organizational Change
For handwashing campaigns to produce lasting change, they must have active involvement and commitment from high-level administration (32). Therefore, senior staff will initiate a “culture of handwashing and patient safety” where everyone is working towards that shared objective (33-34). As a preliminary step, a letter from the CEO or medical director to all employees, volunteers, and physicians would state the leaders’ commitment to handwashing and to the proposed intervention (32). The institution’s name and logo can also appear on campaign materials to show support (31). In addition, top administrators would meet with the chiefs of each medical department, vice president of nursing, or other senior staff to enlist their support in implementing the first two prongs of the intervention. The goal is to ensure that each department has input on the implementation of the intervention, and can modify particular elements if they feel their staff would not respond well to a certain piece. Senior staff would then communicate the details of the intervention to their specific department during staff meetings or in communications materials. This should include information regarding the placement of hand sanitizers, their effectiveness, and ability to reduce skin irritation (35). These leaders would also engage in role modeling of handwashing behaviors. Role modeling would include demonstrating important values and expectations through their own actions and behaviors, as well as acknowledging and encouraging exemplary behavior in others (32).
Feedback and formal recognition are important elements of top-level involvement in the handwashing intervention to establish an institutional culture of handwashing (35-37). Monitoring of the progress of the intervention can be conducted by placing sensors on sanitizer and soap dispensers that count the number of ‘pumps’ taken; measuring the amount of soap and sanitizer used over a given time; or through observation of personnel (37). Recognition can come in the form of public praise at staff meetings or through posting compliance statistics for each unit in staff lounges, for example. Administrators should avoid using monetary rewards because this may take away from the intrinsic reward that one gets from protecting patients or from a “job well done” (36, 38).
Shifting the Frame to Address Power Imbalance and the Physician-Patient Relationship
The patient-centered handwashing intervention is fundamentally flawed because it fails to recognize the power differential between patients and physicians and fear of damaging the physician-patient relationship. Specifically, patients are reluctant to question their providers, especially in ways that might be viewed as confrontational, due to their lack of power and fear their care will suffer (4). Therefore, a handwashing intervention that relies on this questioning is unlikely to succeed as it overlooks significant psychosocial factors that impact behavior. Furthermore, creating a confrontational physician-patient relationship can have a negative effect on patient outcomes because it diminishes the trust and mutual respect required to provide quality care (19). A better alternative is to target the group that will complete the desired outcome, i.e. the providers. Providers have more control over their handwashing behaviors in the hospital setting and are not constrained by these psychosocial factors to the same extent that patients are (15).
The alternative intervention employs Framing Theory to address the above limitations, and sends a message to hospital administrators to shift the frame of handwashing campaigns from a patient-centered approach to one aimed at changing the behavior of providers. Framing Theory relies on redefining the conceptual structure of thinking surrounding a particular issue (39). Therefore, instead using the language of patient “empowerment,” the provider-centered intervention recognizes the inherent power differentials and the likelihood that a button or sticker stating, “Ask me if I have washed my hands,” will not overcome these. The new approach acknowledges that providers possess an unequal amount of knowledge and power, and have more control over their handwashing behaviors than their patients do. Instead of ignoring power differentials, as the patient-centered intervention does, the three-pronged intervention works within the existing hospital power structure to promote change in handwashing behavior. The advertising piece of the intervention directly appeals to the providers’ power and authority with the message, “Take charge of handwashing.” Furthermore, the intervention institutes a top-down approach to initiating the campaign and communicating its objectives (32, 36). It enlists the support of institutional leaders who ‘buy-in’ to the intervention and promote a trickle-down pattern of behavior change (32). In this way, the campaign also minimizes psychological reactance by encouraging department chiefs to role model appropriate handwashing behaviors. While some providers might still experience reactance, it is reduced by making the deliverer of the message more similar to the receiver (i.e. someone from their own department) (40). Furthermore, by reframing the intervention to target the providers directly, damage to the physician-patient relationship does not occur. Patients are not involved in questioning the handwashing behavior of their providers, and consequently a trusting and respectful physician-patient relationship remains intact.
Habit Formation
Evidence presented previously showed the importance of habitual behaviors in daily life (25, 28). A fundamental flaw of the patient-centered intervention is that it relies on the patient’s sporadic questioning to prompt the physician to act and does not create a handwashing habit. Furthermore, the provider-centered strategy changes the behavior at the group-level, as opposed to acting through one-on-one interactions between patients and hospital staff. The implication of a group-level approach is that it will produce a very powerful intervention by changing the behavior of large numbers of people at once.
Each prong of the three-prong intervention works to establish handwashing as a habitual behavior. First, drawing from the environmental component of Social Cognitive Theory (SCT), the intervention institutes physical changes throughout the hospital to cue the habit-forming behavior. According to SCT, the external environment can play a substantial role in shaping behavior (12). Psychological research adds that environmental modifications can significantly impact habitual behavior because they alter cues that trigger performing that behavior (26, 41). By modifying the physical environment of the hospital, this intervention acts on all people that work within the structure to change behavior at the group-level.
The goal of this prong is to make handwashing more convenient and accessible to the staff, thereby increasing the likelihood that they will incorporate handwashing into their routine. Placing alcohol-based hand sanitizers throughout the hospital accomplishes this objective because they act faster, are more effective, and less irritating than traditional handwashing (31, 42). This addresses the major handwashing concerns of the target group, which include busyness, forgetfulness, and skin irritation (31). Because hand sanitizers are quicker and more convenient than finding a sink, providers can regularly use them, even during periods of heavy workload. Placing sanitizers in strategic locations also cues the provider to use them during a routine activity, such as reading a patient chart, so forgetfulness is less likely. Furthermore, alcohol-based sanitizers are very effective, and the Centers for Disease Control and Prevention along with many European countries recommend using them in between patient contact for hands that are not visibly soiled (42-43).
The second prong directly attempts to establish a habit through an advertising campaign. In constructing these messages, the intervention relies heavily on techniques pioneered by the advertising industry, which tie subtle cues to a habitual action with the hope of integrating the product into daily routine (28, 29). Another component of Advertising Theory appeals to deeply held core values and ties them to a product or behavior (29). The intervention team conducts focus groups with the idea of searching for these deeper emotional triggers that motivate behavior. Linking these to handwashing in an advertisement creates salient associations in the minds of the providers that cue them to integrate handwashing into their regular patient care routine (29). For example, one of the proposed campaign messages reads, “Picking up the chart? Don’t pick up an infection. Be sure to wash your hands before greeting your patients.” This cues the habitual action of reading a patient chart and appeals to the nurse or physician’s desire to protect themselves from infection. Appealing to universal or commonly-held core values enables the campaign to affect and change the behavior of many people at once (29, 44-45).
The third, and arguably most important, way this intervention establishes handwashing as a habit among providers is by changing the institutional culture of the hospital to foster handwashing behavior. In creating these large-scale, institutional changes, the culture shifts to make handwashing behaviors become habitual for the hospital as a whole (32-33). Since peer norms are an important predictor of handwashing behavior, establishing a culture where all staff members consider handwashing to be the norm is an effective tool for creating a habit (3, 27). This idea relies on Social Norms Theory, which defines norms as the dominant attitudes, expectations, and behaviors that characterize a group (46). Norms regulate the behavior of groups whose members have a desire to conform to group expectations, and will adopt behaviors to fall in line with the group (46). Through communications and active support for culture change from top management, medical and nursing staff, frequent handwashing becomes the social norm. Senior staff members also act as role models and create a norm of handwashing behavior for their particular unit, and staff seeking to conform to the norm will follow suit (3). This element of behavioral modeling is also recognized by Social Cognitive Theory, which states that individuals observe the behavior of others and the consequences of that behavior for what Bandura termed “vicarious learning” (12). They will engage in or mimic behavior with positive consequences and avoid behaviors with negative outcomes (12). Hence, the feedback and recognition mechanisms are important for all staff members as a form of positive reinforcement to encourage continued handwashing behavior (12, 36-37).
Enlisting senior staff to assist with the intervention also moves towards the goal of establishing an institutional culture of habitual handwashing behavior. This method of selecting senior leaders to relay intervention communications to staff models Social Networking Theory (SNT). Under the SNT, the nature of relationships between individuals is a significant influence on belief and behavior (12). The intervention uses these existing relationships, and identifies a leader in each network to target and spread the intervention to the rest of the group (here, their department) (12). This is essential to the sustainability of the intervention as senior staff would customize the intervention to the particular norms of each department. Therefore, each department would feel involved in and committed to the success of the intervention (31, 34, 36).
Conclusion
In addition to addressing the major flaws of the patient-centered campaigns, this new intervention is stronger and more robust due to its multifaceted approach. Research has shown that single frameworks to address hand hygiene have consistently failed, and multidimensional approaches are needed to achieve lasting change (31, 35, 47). The three-pronged approach produces a stronger intervention than the one-dimensional patient-centered campaigns because it incorporates several aspects to promote habit formation (31).
The power of the three-pronged campaign rests on its ability to change behavior at the group-level, instead of on an individual basis, as the patient-centered intervention does. Understanding the mechanisms by which entire groups adopt behavior change, and incorporating these into an intervention allows it to change the behavior of many providers at once. The provider-centered intervention also takes significant social variables into account. In doing so, it addresses the limitations of the previous campaign and produces a vastly stronger intervention. It shifts the frame from patients to providers to reduce the reliance on an ineffective power dynamic and eliminate the potential damage to the physician-patient relationship. It also develops a three-pronged method to habit formation, providing a long-term strategy for handwashing behavior change among healthcare providers.
REFERENCES
1. Centers for Disease Control and Prevention. Estimates of Healthcare-Associated Infections. Atlanta, GA: Division of Healthcare Quality Promotion. http://www.cdc.gov/ncidod/dhqp/hai.html
2. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings. Morbidity and Mortality Weekly Report. Atlanta, GA: October 25, 2002. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm
3. Sax H et al. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns. Infection Control and Hospital Epidemiology 2007; 28: 1267-1274. http://www.journals.uchicago.edu/doi/pdf/10.1086/521663
4. Landro L. Finding a way to ask doctors tough questions. The Wall Street Journal. March 4, 2009. http://online.wsj.com/article/SB123612654272124081.html
5. The Joint Commission on Accreditation of Healthcare Organizations. Facts about Speak Up Initiatives. Oakbrook Terrace, IL: The Joint Commission. January 24, 2006. http://www.jointcommission.org/GeneralPublic/Speak+Up/about_speakup.htm
6. McGuckin M. Improving handwashing in hospitals: A patient education and empowerment program. LDI Issue Brief 2001; 7(3):1-4. http://www.upenn.edu/ldi/issuebrief7_3.pdf
7. World Health Organization. Improved Hand Hygiene to Prevent Health Care-Associated Infections. Collaborating Centre for Patient Safety Solutions. Patient Safety Solutions 2007; 1(9): 1-4. http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution9.pdf
8. McGuckin M et al. Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit. American Journal of Infection Control 2004; 32:235-238.
9. McGuckin M et al. Patient education model for increasing hand washing compliance. American Journal of Infection Control 1999; 27: 309-314.
10. Gould D, Chudleigh J, Drey N and Moralejo D. Measuring handwashing performance in health service audits and research studies. Journal of Hospital Infection 2007; 66(2): 109-115.
11. Empowering patients to improve safety. Editorial. American Journal of Medical Quality 2006; 21(1): 5-6. http://ajm.sagepub.com/cgi/pdf_extract/21/1/5?rss=1
12. Edberg M. Essentials in Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.
13. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39: 128-135.
14. Rosenstock IM. Historical origins of the Health Belief Model. Health Education Monographs 1974; 2:328-335.
15. Annas GJ. The patient’s right to safety – improving the quality of care through litigation against hospitals. New England Journal of Medicine 2006; 354(19): 2063-2066.
16. Kulczycki A. Husband-wife agreement, power relations and contraceptive use in Turkey. International Family Planning Perspectives 2008; 34(3): 127-137. http://www.guttmacher.org/pubs/journals/3412708.html
17. Bawah AA et al. Women’s fears and men’s anxieties: The impact of family planning on gender relations in northern Ghana. Studies in Family Planning 1999; 30(1): 54-66. http://www.popline.org/docs/1299/141313.html
18. Cobbs v. Grant, 8 Cal. 3d. 229, 502, P.2d 1 (1972).
19. Annas GJ. The Rights of Patients: The Authoritative ACLU Guide to the Rights of Patients. An American Civil Liberties Union Handbook. 3rd Ed. Carbondale: Southern Illinois University Press, 2004.
20. Marella WM et al. Health care consumers’ inclination to engage in selected patient safety practices: A survey of adults in Pennsylvania. Journal of Patient Safety 2007; 3(4): 184-189. http://journals.lww.com/journalpatientsafety/pages/articleviewer.aspx?year=2007&issue=12000&article=00003&type=abstract
21. Lorber J. Good patients and problem patients: Conformity and deviance in a general hospital. Journal of Health and Social Behavior 1975; 16(2): 213-225. http://www.jstor.org/pss/2137163
22. Annas GJ and Healey J. The patient-rights advocate: Redefining the doctor-patient relationship in the hospital context. Vanderbilt Law Review 1974; 27(2): 243-269.
23. Kliman J. Many differences, many voices: Toward social justice in family therapy (Chapter 2). In: Mirkin MO, Suyemoto KL, Okun BF, eds. Psychotherapy with Women: Exploring Diverse Contexts and Identities. New York: The Guilford Press, 2005, 42-63.
24. Dillard JP, and Pfau M. The Persuasion Handbook: Developments in Theory and Practice. Thousand Oaks, CA: Sage, 2002.
25. Quinn JM, and Wood W. Habits across the lifespan. Manuscript submitted for publication, 2004. Cited in: Wood W, Tam L and Witt, MG. Changing circumstances, disrupting habits. Journal of Personality and Social Psychology 2005; 88(6): 918-933.
26. Wood W, Tam L and Witt, MG. Changing circumstances, disrupting habits. Journal of Personality and Social Psychology 2005; 88(6): 918-933.
27. Whitby M, McLaws ML, and Ross M. Why healthcare workers don’t wash their hands: a behavioral explanation. Infection Control and Hospital Epidemiology 2006; 27(5): 484-492. http://www.journals.uchicago.edu/doi/pdf/10.1086/503335
28. Duhigg C. Warning: Habits may be good for you. New York Times. July 13, 2008. http://www.nytimes.com/2008/07/13/business/13habit.html?n=Top/Reference/Times%20Topics/Organizations/V/Vanderbilt%20University&pagewanted=all
29. Curtis et al. Ethics in public health research: Masters of marketing: Bringing private sector skills to public health partnerships. American Journal of Public Health 2007; 97(4):634. http://www.ajph.org/cgi/reprint/97/4/634
30. Naikoba S and Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers – a systematic review. Journal of Hospital Infection 2001; 47(3): 173-180.
31. Pittet D et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000; 356: 1307-1312.
32. Larson E et al. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behavioral Medicine 2000; 26(1): 14-22.
33. Pittet D. Improving adherence to hand hygiene practice: A multidisciplinary approach. Emerging Infectious Diseases 2001; 7(2): 234-240.
34. Pittet D and Boyce JM. Hand hygiene and patient care: Pursuing the Semmelweis legacy. The Lancet 2001: 9-20.
35. Pittet D. Improving compliance with hand hygiene in hospitals. Infection Control and Hospital Epidemiology 2000; 21: 381-386.
36. Cunningham T and Geller E. Organizational behavior management in health care: Applications for large-scale improvements in patient safety. Advances in Patient Safety: New Directions and Alternative Approaches 2008; 2: 1-17. Agency for Healthcare Research and Quality. http://www.ahrq.gov/downloads/pub/advances2/vol2/advances-cunningham_11.pdf
37. Won et al. Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infection Control and Hospital Epidemiology 2004; 25(9):742-746.
38. Ariely D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: Harper Collins, 2008.
39. Lakoff G. Simple Framing. The Rockridge Institute. February 14, 2006. http://www.rockridgeinstitute.org/projects/strategic/simple_framing/
40. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27(3): 2277-284.
41. Havermans RC, Mulkens S, Nederkoorn C, and Jansen A. The efficacy of cue exposure with response prevention in extinguishing drug and alcohol response. Behavioral Interventions 2007; 22:121-135.
42. Boyce JM and Pittet D. Guideline for hand hygiene in health-care settings. Morbidity and Mortality Weekly Report 2002; 51: 1-56. Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
43. Widmer A. Replace hand washing with use of a waterless alcohol hand rub? Clinical Infectious Diseases 2000; 31: 136-143.
44. Urde M. Core value-based corporate brand building. European Journal of Marketing 2003; 37(7/8): 1017-1040.
45. O’Shaughnessy J and O’Shaughnessy N. The Marketing Power of Emotion. New York: Oxford University Press, 2003.
46. Perkins HW. Social norms and the prevention of alcohol misuse in collegiate contexts. Journal of Studies on Alcohol 2002; 14: 164-172.
47. Kretzer EK and Larson EL. Behavioral interventions to improve infection control practices. American Journal of Infection Control 1998; 26: 245-253.
These campaigns are fundamentally flawed because they fail to account for significant social factors that inhibit patients from challenging their providers and fail to accurately predict the behaviors of doctors and hospital workers. These interventions narrow in scope as they are dedicated to changing behavior at the individual level by relying on patients to prompt health care workers to take action on a one-to-one basis. Creators of these campaigns frame their initiatives in terms of “empowering” patients to take an active role in their own safety and seem to rely on Albert Bandura’s concept of self-efficacy, or a person’s belief in his or her ability to take action, to motivate patients to act (11). A sticker or a button serves to remind and encourage patients to question their doctor or nurses’ hand hygiene habits, supposedly empowering them with self-efficacy (11). However, these interventions do not incorporate any environmental or contextual variables that are present in Bandura’s complete Social Cognitive Theory (12). The educational materials provided by some interventions are aimed at increasing patients’ perceived severity and perceived susceptibility to hospital-acquired infections. This directly follows the Health Belief Model (HBM), which states that individuals will rationally weigh the costs and benefits of an action and choose whether to perform an action based on this calculation (13-14). By increasing the patients’ perceived severity and perceived susceptibility to infections, this increases the perceived benefit of asking a provider if he or she washed his or her hands. So-called “empowering” patients through campaign materials would reduce the patients’ perceived barriers to performing the action under the HBM. The sticker or button serves a cue, or trigger, for the patient to question the provider about handwashing (14).
It is important to note that these interventions target the patients to ultimately change the behavior of another group – health care providers. The patient will not be completing the action that is the desired outcome (i.e. handwashing). The patients’ questioning will provide a cue to action, or an external event that will motivate the nurse or physician to act (12). The health care worker must ultimately complete the action, and as I will argue later, make it a habit in order to be effective in reducing infection transmission. Because the intervention targets and relies on a secondary group to prompt the group of interest, it allows for more potential missteps in the process to achieve the desired outcome.
While these campaigns purport the well-intentioned goal of increasing patient involvement in their care, a “self-defense” strategy to patient safety is questionable at best (15). These campaigns wrongly put the onus on the patients to ensure their own safety “in an environment over which they have no control” (15, p. 2065). These types of interventions fail to consider crucial group-level variables such as power dynamics; fear of damaging the physician-patient relationship; and lack of habitual action that severely limits the effectiveness of the intervention. These factors make it difficult for patients to follow the advice on the buttons and voice their concerns regarding their providers’ hand washing behavior in the first place, and even if this is accomplished, these interventions do not provide a good long-term strategy to make handwashing behavior a more regular occurrence in hospital settings.
Power Imbalance
Lessons from other public health and social science domains teach us that power differentials between individuals can have a substantial impact on individual behavior. This is evident in condom negotiations where gender-based power differentials in traditional societies lead to lower contraceptive use (16). In these instances, women fear that a husband’s disapproval of contraceptives will lead to loss of affection or divorce (17). In the hospital setting, the provider is in a position of power as patients generally do not possess extensive knowledge of medical sciences. This makes patients ‘abjectly dependent’ on their physicians for information and for treatment (18). Furthermore, patients enter into the hospital when they are sick, scared, and vulnerable. In a fragile mental and physical state, patients may not be able to assert their rights effectively or have the “presence of mind” to ask questions regarding handwashing (4, p.1). In this situation, patients are naturally reluctant to raise any issues that may be viewed as confrontational, such as asking hospital workers if they have washed their hands (4, 20). These interventions fail to consider the ramifications of power differentials in the hospital room, or falsely assume that a button or a sticker will be sufficient to override these imbalances.
The interventions also neglect to account emotional factors, such as the fear experienced by patients in a hospital facility. As mentioned in the contraceptive example, fear is a common emotion associated with power imbalance (17). Here, patients may feel they will not receive adequate treatment if they question their caregivers’ authority or ability to keep them free of infection (4). A study by Judith Lorber, which will be revisited later, found that most patients resented the passivity and submissiveness that characterize a patient’s perceived role in the rigid hospital structure. However, most hospitalized patients felt that this was the proper way to act, and that if they did not “keep Quiet,” their care would suffer as a result (21, p.214). George Annas and Joseph Healey echo, “Because a sick person’s first concern is to regain health, he is willing to give up rights that otherwise would be vigorously asserted” (22, p. 245). Ignoring larger, psychosocial factors that drive human behavior, as these interventions have done, is a significant error.
This power differential is amplified with particular populations such as the elderly, non-English speakers, and patients lacking health insurance. Elderly patients tend to be more passive with doctors as medical paternalism, or the notion that the “doctor knows best” and makes decisions for the patients, is more common among older generations (4, 19, p. 113). Aside from the obvious technical issues that non-English speakers would have reading the buttons and verbalizing a response, disadvantaged populations experience an even greater power differential with their physicians or other hospital staff. A patient lacking health insurance may think a physician is “doing them a favor” by treating their ailments under such circumstances, therefore, would not want to raise any issues that might jeopardize their treatment. Jodie Kliman recounts her personal experience waiting in an emergency room, and demanding an intervention from the hospital staff when her husband’s condition became increasingly severe. Reflecting on this experience, she questions whether she would be a widow today had she been of a different class or racial group and less willing or unable to assert herself in the hospital setting (23). She writes, “Many forms of privilege and power, or lack thereof, contribute to our interactions and beliefs… They permeate what we say, what and whom it silences, what we notice or overlook. They operate for those with privilege, and those without” (23, p. 43). These underlying forces were undoubted not considered in this intervention and leave it substantially lacking, particularly with respect to vulnerable populations.
The Physician-Patient Relationship
Based on the information presented in the previous section, the patient-centered handwashing initiative is likely to remain ineffective as patients are in a weaker position in the power hierarchy of a hospital setting and are therefore unlikely to assert themselves. This section will argue that the “ask me if I have washed my hands” intervention is not only ineffective, but has a negative effect on patient outcomes. The intervention fails to consider the broader aspects concerning the nature of the physician-patient relationship, the emotions involved, and the consequences of damaging it. While this paper uses the term, physician-patient relationship, this dynamic can also be applied to other types of providers and caregivers in the hospital setting.
Although the physician-patient relationship has deep historical roots, legal doctrines have outlined the duties of a physician that arise from the fiduciary (trust) nature of the relationship and presence of information asymmetries (18-19). The physician-patient relationship is more than a business-like transaction or simple exchange of information; it involves trust and compassion to make the patient feel comfortable relaying sensitive information to the physician and engaging in a meaningful discussion regarding treatment options (19). The handwashing intervention damages the physician-patient relationship by creating an atmosphere of confrontation, instead of one based on trust and mutual respect. When these qualities are not present, physicians are unable to obtain truthful and complete information from their patients, and patient care suffers as a consequence. Questioning a physician as to whether he or she washed his or her hands creates a combative relationship from the minute the physician enters the room. This interaction instills emotions of resentment and distrust that damage the physician-patient relationship. The failure of the intervention to consider the importance of the integrity of this relationship and the various emotions involved is a serious oversight.
Furthermore, physician education and training can lead to physicians being resistant to patients questioning their authority. Dr. Bruce Siegel comments that many physicians are taught to “think of themselves as little gods,” and would view a challenge to their handwashing habits from their patients as an affront to their authority and professional ability (4, p. 2). Many physicians might not even wear the buttons if they call these deeply engrained values into question. Physicians could also perceive their patients’ questioning as a threat to their personal or professional freedoms. The theory of psychological reactance states that any message that attempts to change behavior could be perceived as a threat to freedom. The mind reacts to preserve freedom by ignoring the request or performing more of the undesired behavior (24). Applied to this context, physicians might experience psychological reactance to a patient challenge (i.e. asking if the physician washed his or her hands) and refuse to take the suggested action. Anecdotal evidence indicates that physicians wash their hands when asked around 60% of the time, but do so quickly and begrudgingly (4, 8). This limits the quality of handwashing behavior (increasing the potential for pathogen transmission) and could possibly reduce the providers’ inclination to wash their hands in the future if they perceive this campaign as a threat to their freedom. The campaign’s failure to consider psychological reactance, and its potential effects on the quality of handwashing at the patient bedside and future consequences for physician behavior could lead to an increase in hospital infection rates.
As previously mentioned, this intervention does not take into account the emotion of fear experienced by most patients that they will not receive adequate care if they question the behavior of their doctors or nurses. A study by Judith Lorber may substantiate these fears, as it documents the possible consequences for patients who go against established hospital norms. Patients who were viewed by staff as cooperative, stoic, and uncomplaining were labeled “good patients.” Those patients who complained when staff felt it was medically unwarranted, were less submissive and, “did not subscribe to the norm of unquestioning obedience” were labeled “problem patients” (21, p. 217). The study found that patients labeled “problem patients” were more likely to be tranquilized or discharged early (21). The hang hygiene interventions could establish, and even encourage, more patients to become “problem patients” in the eyes of the staff. This damages the cooperative relationship between patients and caregivers, potentially leading to a decline in patient health status.
Habit Formation
The patient-centered handwashing intervention is further limited in its failure to establish staff handwashing behavior as a habitual activity. Evidence from psychology and behavioral science indicates that habitual actions govern a substantial part of daily life. Up to 47% of a person’s activities are conducted every day, usually in the same location (25). This consistency establishes what social scientists call habits or, “behavioral dispositions to repeat well-practiced actions given recurring circumstances” (26, p. 918). Much of our behavior (including handwashing) is regulated by habit, rather than by thoughtful consideration (27). Professional marketers and consumer psychologists know this concept well, and for years have sought manufacture habits by integrating consumer products into daily behavior (28). Advertising techniques use subtle habitual cues to tie products to a behavior. For example, Proctor and Gamble created an advertising campaign for Febreze that tied using the perfume to cleaning a room, something their target audience did daily, and sales soared (29).
The “ask me if I have washed my hands” campaign fails to consider the influence of ritual and habit over frequent behaviors. While doctors and nurses are presumably aware of the importance of handwashing in reducing disease transmission, the high frequency of handwashing behavior leads to a reduced consideration for the reasons for performing the behavior (3). Therefore, subtle cues and regular associations should be established in healthcare facilities to foster habit-formation. The patient-centered campaigns exclusively rely on an overt external cue, i.e. the patient prompt, for the behavior to take place. The sporadic nature of patient questioning fails to establish consistency in the hospital worker’s routine, thereby weakening the habitual nature of the action and likelihood that the action will take place on a regular basis (30).
The campaign is further limited because this interaction takes place at the individual-level, with one-on-one discussions between providers and patients. A more effective strategy, such as the one mentioned in the previous paragraph, would seek to change the behavior of healthcare providers as a group. One potential mechanism by which this might be accomplished would be to create salient associations in the minds of physicians to wash their hands every time they enter a patient’s room. The current campaign makes no attempt to establish linkages between a habitual cue and the provider’s handwashing behavior. These linkages proved to be a useful and successful tool in consumer product advertising, a strategy that is readily adaptable to public health interventions like handwashing (29).
Summary of Limitations
While the incorporation of patients and their families into medical decision-making is a noble purpose, the “ask me if I have washed my hands” strategy is misguided as it puts the responsibility for patient safety on the patients themselves. The patients’ control over the situation is limited, and the campaign does not produce an effective long-term strategy for improvements in hospital infection control. The campaigns fail to consider the inherent power imbalances that occur between patients and their caregivers that contribute to a patient’s reluctance to question hand hygiene habits. The interventions also foster a confrontational physician-patient relationship that can be counterproductive to providing patients with quality care. Since the interventions rely on patients to prompt their providers to wash their hands, providers do not create or maintain habitual handwashing behavior. Simply put: (1) it is unlikely that patients will question their providers in the first place; (2) if they do raise the issue, it may carry negative health consequences; and (3) this is not a viable strategy to produce lasting change.
The failure of these campaigns to consider the larger, group-level variables like power differentials, the importance of provider relationships, and habit formation are their downfall. Their narrow scope and individual focus have limited their effectiveness, and potentially caused declines in quality of care, to the detriment of patient safety in hospital settings.
Reintroducing a Role for Health Care Providers in Handwashing Campaigns
Patient-centered handwashing campaigns for health care workers present a faulty approach to reducing pathogen transmission in healthcare facilities. These interventions are not likely to achieve lasting effects on handwashing rates because they ignore significant social factors that influence both patient and provider behavior. The limitations of these campaigns include a failure to consider the power imbalance between patients and healthcare workers; the importance of preserving the physician-patient relationship; and the necessity of habit formation in handwashing behavior. Recognizing these limitations, this paper will propose a more comprehensive alternative to patient-centered handwashing interventions that addresses these three flaws and establishes long-term habit formation by changing behavior at the group-level.
Counter-Proposal: A Brief Outline
A patient-centered campaign to promote hospital handwashing relies on an ineffective power dynamic to change behavior and damages the physician-patient relationship. To address these two limitations, the frame of the intervention will shift to focus on changing the behavior of providers instead of patients.
Secondly, the patient-centered interventions rely on patients to prompt physician or nurse handwashing. This fails to establish handwashing as a habitual behavior, which is crucial for the long-term effectiveness of a campaign (26, 28). This counter-proposal introduces a three-pronged approach to creating a handwashing habit among providers. First, the intervention changes the hospital environment to make handwashing easier and more accessible. Second, advertising messages are developed to foster associations and cue providers to engage in handwashing activity. Third, the intervention encourages a change in institutional culture by working with top-level officials to make handwashing a priority for the facility. In developing and executing the provider-centered intervention, the reasons healthcare workers commonly cite for not washing their hands are taken into account. These include being too busy, forgetfulness, and skin irritation (31). Peer norms are also considered as they are significant predictors of handwashing behavior (27).
The Three-Pronged Approach
1) Changing the Hospital Environment
In order to make handwashing more convenient, alcohol-based sanitizers are placed in strategic locations in or outside patient rooms. To identify a suitable location for the dispenser, focus groups or observational research will be conducted to determine the activities most providers complete before entering a patient room. For example, hospitals usually keep a chart of patient information outside of the patient’s room. If providers routinely review this information before interacting with a patient, dispensers could be placed on the container that holds the chart as a reminder to sanitize hands. This would cue providers to use the sanitizer and incorporate it into their patient care routine. Multiple locations or distribution methods for hand sanitizer would be tested to determine which is the most effective. These could include dispensers at the patient bedside or individual-sized bottles given to doctors and nurses to keep in their pockets.
2) Advertising Campaign
Prong two of the intervention is the development of campaign messages linking handwashing behavior to habitual actions. First, focus groups will be conducted among different segments of hospital staff to better understand what motivates handwashing behavior and to determine what their core values might be (since protecting patients may not be the primary motivator for handwashing). For example, one series of questions could assess whether caregivers wash their hands because they are afraid of getting an illness from their patients. If this is the case, the advertising message could integrate the patient chart as the environmental cue and ask, “Picking up a chart? Don’t pick up an infection. Be sure to wash your hands before greeting your patients.” The focus groups would also investigate cues hospital workers associate with handwashing. If eating is a common cue, the advertising message could be constructed around cuing food and might read, “Would you eat with those hands? Wash up.” An example of appealing to a core value would be to appeal to a physician’s sense of authority with the message “Take charge of handwashing” in the campaign materials.
To assess the most effective campaign medium, the intervention team would probe the focus groups on ways they gather and receive information. Focus groups could be asked to identify which magazines, medical or nursing journals, and newspapers they read. Providers could also be asked if they would watch a video clip emailed to the hospital listserv, or if posters placed in the staff lounges would be readily noticed.
3) Organizational Change
For handwashing campaigns to produce lasting change, they must have active involvement and commitment from high-level administration (32). Therefore, senior staff will initiate a “culture of handwashing and patient safety” where everyone is working towards that shared objective (33-34). As a preliminary step, a letter from the CEO or medical director to all employees, volunteers, and physicians would state the leaders’ commitment to handwashing and to the proposed intervention (32). The institution’s name and logo can also appear on campaign materials to show support (31). In addition, top administrators would meet with the chiefs of each medical department, vice president of nursing, or other senior staff to enlist their support in implementing the first two prongs of the intervention. The goal is to ensure that each department has input on the implementation of the intervention, and can modify particular elements if they feel their staff would not respond well to a certain piece. Senior staff would then communicate the details of the intervention to their specific department during staff meetings or in communications materials. This should include information regarding the placement of hand sanitizers, their effectiveness, and ability to reduce skin irritation (35). These leaders would also engage in role modeling of handwashing behaviors. Role modeling would include demonstrating important values and expectations through their own actions and behaviors, as well as acknowledging and encouraging exemplary behavior in others (32).
Feedback and formal recognition are important elements of top-level involvement in the handwashing intervention to establish an institutional culture of handwashing (35-37). Monitoring of the progress of the intervention can be conducted by placing sensors on sanitizer and soap dispensers that count the number of ‘pumps’ taken; measuring the amount of soap and sanitizer used over a given time; or through observation of personnel (37). Recognition can come in the form of public praise at staff meetings or through posting compliance statistics for each unit in staff lounges, for example. Administrators should avoid using monetary rewards because this may take away from the intrinsic reward that one gets from protecting patients or from a “job well done” (36, 38).
Shifting the Frame to Address Power Imbalance and the Physician-Patient Relationship
The patient-centered handwashing intervention is fundamentally flawed because it fails to recognize the power differential between patients and physicians and fear of damaging the physician-patient relationship. Specifically, patients are reluctant to question their providers, especially in ways that might be viewed as confrontational, due to their lack of power and fear their care will suffer (4). Therefore, a handwashing intervention that relies on this questioning is unlikely to succeed as it overlooks significant psychosocial factors that impact behavior. Furthermore, creating a confrontational physician-patient relationship can have a negative effect on patient outcomes because it diminishes the trust and mutual respect required to provide quality care (19). A better alternative is to target the group that will complete the desired outcome, i.e. the providers. Providers have more control over their handwashing behaviors in the hospital setting and are not constrained by these psychosocial factors to the same extent that patients are (15).
The alternative intervention employs Framing Theory to address the above limitations, and sends a message to hospital administrators to shift the frame of handwashing campaigns from a patient-centered approach to one aimed at changing the behavior of providers. Framing Theory relies on redefining the conceptual structure of thinking surrounding a particular issue (39). Therefore, instead using the language of patient “empowerment,” the provider-centered intervention recognizes the inherent power differentials and the likelihood that a button or sticker stating, “Ask me if I have washed my hands,” will not overcome these. The new approach acknowledges that providers possess an unequal amount of knowledge and power, and have more control over their handwashing behaviors than their patients do. Instead of ignoring power differentials, as the patient-centered intervention does, the three-pronged intervention works within the existing hospital power structure to promote change in handwashing behavior. The advertising piece of the intervention directly appeals to the providers’ power and authority with the message, “Take charge of handwashing.” Furthermore, the intervention institutes a top-down approach to initiating the campaign and communicating its objectives (32, 36). It enlists the support of institutional leaders who ‘buy-in’ to the intervention and promote a trickle-down pattern of behavior change (32). In this way, the campaign also minimizes psychological reactance by encouraging department chiefs to role model appropriate handwashing behaviors. While some providers might still experience reactance, it is reduced by making the deliverer of the message more similar to the receiver (i.e. someone from their own department) (40). Furthermore, by reframing the intervention to target the providers directly, damage to the physician-patient relationship does not occur. Patients are not involved in questioning the handwashing behavior of their providers, and consequently a trusting and respectful physician-patient relationship remains intact.
Habit Formation
Evidence presented previously showed the importance of habitual behaviors in daily life (25, 28). A fundamental flaw of the patient-centered intervention is that it relies on the patient’s sporadic questioning to prompt the physician to act and does not create a handwashing habit. Furthermore, the provider-centered strategy changes the behavior at the group-level, as opposed to acting through one-on-one interactions between patients and hospital staff. The implication of a group-level approach is that it will produce a very powerful intervention by changing the behavior of large numbers of people at once.
Each prong of the three-prong intervention works to establish handwashing as a habitual behavior. First, drawing from the environmental component of Social Cognitive Theory (SCT), the intervention institutes physical changes throughout the hospital to cue the habit-forming behavior. According to SCT, the external environment can play a substantial role in shaping behavior (12). Psychological research adds that environmental modifications can significantly impact habitual behavior because they alter cues that trigger performing that behavior (26, 41). By modifying the physical environment of the hospital, this intervention acts on all people that work within the structure to change behavior at the group-level.
The goal of this prong is to make handwashing more convenient and accessible to the staff, thereby increasing the likelihood that they will incorporate handwashing into their routine. Placing alcohol-based hand sanitizers throughout the hospital accomplishes this objective because they act faster, are more effective, and less irritating than traditional handwashing (31, 42). This addresses the major handwashing concerns of the target group, which include busyness, forgetfulness, and skin irritation (31). Because hand sanitizers are quicker and more convenient than finding a sink, providers can regularly use them, even during periods of heavy workload. Placing sanitizers in strategic locations also cues the provider to use them during a routine activity, such as reading a patient chart, so forgetfulness is less likely. Furthermore, alcohol-based sanitizers are very effective, and the Centers for Disease Control and Prevention along with many European countries recommend using them in between patient contact for hands that are not visibly soiled (42-43).
The second prong directly attempts to establish a habit through an advertising campaign. In constructing these messages, the intervention relies heavily on techniques pioneered by the advertising industry, which tie subtle cues to a habitual action with the hope of integrating the product into daily routine (28, 29). Another component of Advertising Theory appeals to deeply held core values and ties them to a product or behavior (29). The intervention team conducts focus groups with the idea of searching for these deeper emotional triggers that motivate behavior. Linking these to handwashing in an advertisement creates salient associations in the minds of the providers that cue them to integrate handwashing into their regular patient care routine (29). For example, one of the proposed campaign messages reads, “Picking up the chart? Don’t pick up an infection. Be sure to wash your hands before greeting your patients.” This cues the habitual action of reading a patient chart and appeals to the nurse or physician’s desire to protect themselves from infection. Appealing to universal or commonly-held core values enables the campaign to affect and change the behavior of many people at once (29, 44-45).
The third, and arguably most important, way this intervention establishes handwashing as a habit among providers is by changing the institutional culture of the hospital to foster handwashing behavior. In creating these large-scale, institutional changes, the culture shifts to make handwashing behaviors become habitual for the hospital as a whole (32-33). Since peer norms are an important predictor of handwashing behavior, establishing a culture where all staff members consider handwashing to be the norm is an effective tool for creating a habit (3, 27). This idea relies on Social Norms Theory, which defines norms as the dominant attitudes, expectations, and behaviors that characterize a group (46). Norms regulate the behavior of groups whose members have a desire to conform to group expectations, and will adopt behaviors to fall in line with the group (46). Through communications and active support for culture change from top management, medical and nursing staff, frequent handwashing becomes the social norm. Senior staff members also act as role models and create a norm of handwashing behavior for their particular unit, and staff seeking to conform to the norm will follow suit (3). This element of behavioral modeling is also recognized by Social Cognitive Theory, which states that individuals observe the behavior of others and the consequences of that behavior for what Bandura termed “vicarious learning” (12). They will engage in or mimic behavior with positive consequences and avoid behaviors with negative outcomes (12). Hence, the feedback and recognition mechanisms are important for all staff members as a form of positive reinforcement to encourage continued handwashing behavior (12, 36-37).
Enlisting senior staff to assist with the intervention also moves towards the goal of establishing an institutional culture of habitual handwashing behavior. This method of selecting senior leaders to relay intervention communications to staff models Social Networking Theory (SNT). Under the SNT, the nature of relationships between individuals is a significant influence on belief and behavior (12). The intervention uses these existing relationships, and identifies a leader in each network to target and spread the intervention to the rest of the group (here, their department) (12). This is essential to the sustainability of the intervention as senior staff would customize the intervention to the particular norms of each department. Therefore, each department would feel involved in and committed to the success of the intervention (31, 34, 36).
Conclusion
In addition to addressing the major flaws of the patient-centered campaigns, this new intervention is stronger and more robust due to its multifaceted approach. Research has shown that single frameworks to address hand hygiene have consistently failed, and multidimensional approaches are needed to achieve lasting change (31, 35, 47). The three-pronged approach produces a stronger intervention than the one-dimensional patient-centered campaigns because it incorporates several aspects to promote habit formation (31).
The power of the three-pronged campaign rests on its ability to change behavior at the group-level, instead of on an individual basis, as the patient-centered intervention does. Understanding the mechanisms by which entire groups adopt behavior change, and incorporating these into an intervention allows it to change the behavior of many providers at once. The provider-centered intervention also takes significant social variables into account. In doing so, it addresses the limitations of the previous campaign and produces a vastly stronger intervention. It shifts the frame from patients to providers to reduce the reliance on an ineffective power dynamic and eliminate the potential damage to the physician-patient relationship. It also develops a three-pronged method to habit formation, providing a long-term strategy for handwashing behavior change among healthcare providers.
REFERENCES
1. Centers for Disease Control and Prevention. Estimates of Healthcare-Associated Infections. Atlanta, GA: Division of Healthcare Quality Promotion. http://www.cdc.gov/ncidod/dhqp/hai.html
2. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care Settings. Morbidity and Mortality Weekly Report. Atlanta, GA: October 25, 2002. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm
3. Sax H et al. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns. Infection Control and Hospital Epidemiology 2007; 28: 1267-1274. http://www.journals.uchicago.edu/doi/pdf/10.1086/521663
4. Landro L. Finding a way to ask doctors tough questions. The Wall Street Journal. March 4, 2009. http://online.wsj.com/article/SB123612654272124081.html
5. The Joint Commission on Accreditation of Healthcare Organizations. Facts about Speak Up Initiatives. Oakbrook Terrace, IL: The Joint Commission. January 24, 2006. http://www.jointcommission.org/GeneralPublic/Speak+Up/about_speakup.htm
6. McGuckin M. Improving handwashing in hospitals: A patient education and empowerment program. LDI Issue Brief 2001; 7(3):1-4. http://www.upenn.edu/ldi/issuebrief7_3.pdf
7. World Health Organization. Improved Hand Hygiene to Prevent Health Care-Associated Infections. Collaborating Centre for Patient Safety Solutions. Patient Safety Solutions 2007; 1(9): 1-4. http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution9.pdf
8. McGuckin M et al. Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit. American Journal of Infection Control 2004; 32:235-238.
9. McGuckin M et al. Patient education model for increasing hand washing compliance. American Journal of Infection Control 1999; 27: 309-314.
10. Gould D, Chudleigh J, Drey N and Moralejo D. Measuring handwashing performance in health service audits and research studies. Journal of Hospital Infection 2007; 66(2): 109-115.
11. Empowering patients to improve safety. Editorial. American Journal of Medical Quality 2006; 21(1): 5-6. http://ajm.sagepub.com/cgi/pdf_extract/21/1/5?rss=1
12. Edberg M. Essentials in Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett, 2007.
13. Salazar MK. Comparison of four behavioral theories. AAOHN Journal 1991; 39: 128-135.
14. Rosenstock IM. Historical origins of the Health Belief Model. Health Education Monographs 1974; 2:328-335.
15. Annas GJ. The patient’s right to safety – improving the quality of care through litigation against hospitals. New England Journal of Medicine 2006; 354(19): 2063-2066.
16. Kulczycki A. Husband-wife agreement, power relations and contraceptive use in Turkey. International Family Planning Perspectives 2008; 34(3): 127-137. http://www.guttmacher.org/pubs/journals/3412708.html
17. Bawah AA et al. Women’s fears and men’s anxieties: The impact of family planning on gender relations in northern Ghana. Studies in Family Planning 1999; 30(1): 54-66. http://www.popline.org/docs/1299/141313.html
18. Cobbs v. Grant, 8 Cal. 3d. 229, 502, P.2d 1 (1972).
19. Annas GJ. The Rights of Patients: The Authoritative ACLU Guide to the Rights of Patients. An American Civil Liberties Union Handbook. 3rd Ed. Carbondale: Southern Illinois University Press, 2004.
20. Marella WM et al. Health care consumers’ inclination to engage in selected patient safety practices: A survey of adults in Pennsylvania. Journal of Patient Safety 2007; 3(4): 184-189. http://journals.lww.com/journalpatientsafety/pages/articleviewer.aspx?year=2007&issue=12000&article=00003&type=abstract
21. Lorber J. Good patients and problem patients: Conformity and deviance in a general hospital. Journal of Health and Social Behavior 1975; 16(2): 213-225. http://www.jstor.org/pss/2137163
22. Annas GJ and Healey J. The patient-rights advocate: Redefining the doctor-patient relationship in the hospital context. Vanderbilt Law Review 1974; 27(2): 243-269.
23. Kliman J. Many differences, many voices: Toward social justice in family therapy (Chapter 2). In: Mirkin MO, Suyemoto KL, Okun BF, eds. Psychotherapy with Women: Exploring Diverse Contexts and Identities. New York: The Guilford Press, 2005, 42-63.
24. Dillard JP, and Pfau M. The Persuasion Handbook: Developments in Theory and Practice. Thousand Oaks, CA: Sage, 2002.
25. Quinn JM, and Wood W. Habits across the lifespan. Manuscript submitted for publication, 2004. Cited in: Wood W, Tam L and Witt, MG. Changing circumstances, disrupting habits. Journal of Personality and Social Psychology 2005; 88(6): 918-933.
26. Wood W, Tam L and Witt, MG. Changing circumstances, disrupting habits. Journal of Personality and Social Psychology 2005; 88(6): 918-933.
27. Whitby M, McLaws ML, and Ross M. Why healthcare workers don’t wash their hands: a behavioral explanation. Infection Control and Hospital Epidemiology 2006; 27(5): 484-492. http://www.journals.uchicago.edu/doi/pdf/10.1086/503335
28. Duhigg C. Warning: Habits may be good for you. New York Times. July 13, 2008. http://www.nytimes.com/2008/07/13/business/13habit.html?n=Top/Reference/Times%20Topics/Organizations/V/Vanderbilt%20University&pagewanted=all
29. Curtis et al. Ethics in public health research: Masters of marketing: Bringing private sector skills to public health partnerships. American Journal of Public Health 2007; 97(4):634. http://www.ajph.org/cgi/reprint/97/4/634
30. Naikoba S and Hayward A. The effectiveness of interventions aimed at increasing handwashing in healthcare workers – a systematic review. Journal of Hospital Infection 2001; 47(3): 173-180.
31. Pittet D et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000; 356: 1307-1312.
32. Larson E et al. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behavioral Medicine 2000; 26(1): 14-22.
33. Pittet D. Improving adherence to hand hygiene practice: A multidisciplinary approach. Emerging Infectious Diseases 2001; 7(2): 234-240.
34. Pittet D and Boyce JM. Hand hygiene and patient care: Pursuing the Semmelweis legacy. The Lancet 2001: 9-20.
35. Pittet D. Improving compliance with hand hygiene in hospitals. Infection Control and Hospital Epidemiology 2000; 21: 381-386.
36. Cunningham T and Geller E. Organizational behavior management in health care: Applications for large-scale improvements in patient safety. Advances in Patient Safety: New Directions and Alternative Approaches 2008; 2: 1-17. Agency for Healthcare Research and Quality. http://www.ahrq.gov/downloads/pub/advances2/vol2/advances-cunningham_11.pdf
37. Won et al. Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infection Control and Hospital Epidemiology 2004; 25(9):742-746.
38. Ariely D. Predictably Irrational: The Hidden Forces That Shape Our Decisions. New York, NY: Harper Collins, 2008.
39. Lakoff G. Simple Framing. The Rockridge Institute. February 14, 2006. http://www.rockridgeinstitute.org/projects/strategic/simple_framing/
40. Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27(3): 2277-284.
41. Havermans RC, Mulkens S, Nederkoorn C, and Jansen A. The efficacy of cue exposure with response prevention in extinguishing drug and alcohol response. Behavioral Interventions 2007; 22:121-135.
42. Boyce JM and Pittet D. Guideline for hand hygiene in health-care settings. Morbidity and Mortality Weekly Report 2002; 51: 1-56. Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
43. Widmer A. Replace hand washing with use of a waterless alcohol hand rub? Clinical Infectious Diseases 2000; 31: 136-143.
44. Urde M. Core value-based corporate brand building. European Journal of Marketing 2003; 37(7/8): 1017-1040.
45. O’Shaughnessy J and O’Shaughnessy N. The Marketing Power of Emotion. New York: Oxford University Press, 2003.
46. Perkins HW. Social norms and the prevention of alcohol misuse in collegiate contexts. Journal of Studies on Alcohol 2002; 14: 164-172.
47. Kretzer EK and Larson EL. Behavioral interventions to improve infection control practices. American Journal of Infection Control 1998; 26: 245-253.
Labels: Blue, Health Care, Health Communication, Infectious Disease, Influenza
posted by LB @ 7:09 AM
0 Comments:
Post a Comment
Subscribe to Post Comments [Atom]
<< Home