Hand hygiene seems like it should be a simple practice - why is it so complex?
Dr. Srigley: Seemingly simple actions like hand hygiene are complicated because many different factors determine whether a person does them or not. According to the theory of planned behaviour, three factors determine whether or not we do something: attitude (how we feel about it); subjective norms (how we believe other people feel about it); and perceived behavioural control (whether or not we feel we can do it). Those three factors contribute to our intention, which then leads to action. External factors play a role as well, such as how busy we are and features of the environment.
As health care providers we tend to believe that providing education and showing people the evidence should be enough to support change, but the purpose of education is to increase knowledge - not change behaviour. If lack of knowledge was the only limiting factor then education would be enough, but so many other factors play a role in behaviour.What can we learn from the science of behaviour change and hand hygiene?
Dr. Srigley: There is much from psychology that we can apply to hand hygiene behaviour. One example is a principle called the “foot in the door” technique: if you ask someone to comply with a small request, they are more likely to agree to a larger request later on. We could ask people to sign a pledge committing to hand hygiene, and they may be more likely to ensure that they perform hand hygiene later, because they have a psychological drive to be consistent with what they’ve done before. Another example is the principle of social proof: that we look to see what others are doing in order to know what we should be doing. People want to be part of the majority because they perceive what the majority does as being "right", so a message such as “Health care workers perform hand hygiene only 40% of the time” may actually encourage people not to wash their hands. We have to be very careful about how we frame our messages. We need to use behavioural frameworks to determine the reasons for low hand hygiene compliance and then target our interventions to address the underlying problems. A simple fix like adequate access to alcohol-based hand rub may do the trick in some situations, but in many cases there are deeper issues at play. We also need to start doing psychological studies of hand hygiene interventions, and using approaches that are rooted in behavioural theory. Infection prevention and control has typically been the realm of health care professionals and we tend not to collaborate with people outside of health care. We need to start thinking beyond traditional infection control approaches and begin working with people in other disciplines, including those with expertise in psychology and behaviour change. One way to start to do this is by inviting everyone from all disciplines within our organizations to work together on improving hand hygiene rather than having a purely top-down program. For more information on applying the science of behaviour change to hand hygiene, please visit the presentations from the JCYH Symposium. Where should we focus our efforts to enhance hand hygiene practice?Dr. Srigley: Education and evidence aren’t enough on their own. The normative beliefs from the theory of planned behaviour play an important role in hand hygiene and we need to address organizational culture in order to change those norms. Encouraging front-line ownership of infection prevention and control issues is a promising strategy - helping groups of health care professionals solve problems in ways that work best for them.
About Dr. Jocelyn Srigley
Dr. Srigley is the Associate Medical Director of IPAC at Hamilton Health Sciences and an Assistant Professor at McMaster University. She is also a part-time IPAC Physician at Public Health Ontario.