Psychological Factors of Hand Hygiene. Presented by: Dr. Maryanne McGuckin, FSHEA

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1 Psychological Factors of Hand Hygiene Presented by: Dr. Maryanne McGuckin, FSHEA

2 Disclosure Currently, McGuckin Methods International has a consulting agreement for clinical trials with Hand-In-Scan. No material presented will be related to Hand-in-Scan products.

3 McGuckin Methods International Mission: Pioneering effective methods for safe healthcare delivery through research, education and advocacy. Academic Career: Faculty of the University of Pennsylvania

4 Psychological Factors: DEFINED Psychological factors refer to: 1. Thoughts 2. Feelings 3. Cognitive characteristics that affect the attitude, behavior and functions of the human mind. HCWs, Patients and Consumers have different factors that affect HHC.

5 Dr. McGuckin s Psychology on Hand Hygiene Healthcare Workers: Just do it Patients: Just do it for me Consumers: Empower me Researchers: Focus on positive and what works Be Passionate. Be Persuasive.

6 Learning Objectives Review the Status Review the status of hand hygiene (HH) compliance Review Current Research Review the current research and practice regarding psychology of hand hygiene by HCW, Patient and Consumer Learn how to be Persuasive

7 Healthcare Associated Infections (HAIs) Cost: Total annual costs for the 5 major infections: $9.8 billion JAMA Intern Med Dec 9-23;173(22): Cost when including social impact: $ billion J Med Econ Dec;16(12): Burden: 1 out of every 25 patients in U.S. hospitals affected by an HAI N Engl J Med Mar 27;370(13): WHO Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection Recent studies conducted in Europe reported hospital-wide prevalence rates of patients affected by HAIs ranging from 4.6% to 9.3% (2013).

8 Compliance in U.S.: Multicenter Despite overwhelming evidence that hand hygiene programs reduce the spread of HAIs, compliance is at or below 50% - even after consistent education, measurement and feedback. McGuckin M, Waterman R, Govednik J. Hand Hygiene Compliance in US. A Multicenter Evaluation using Product Volume Measurement and Feedback. American Journal of Medical Quality 24(3) Month ICU Non-ICU Compliance Compliance Baseline 26% 36% 1 29% 36% 2 29% 39% 3 31% 39% 4 37% 44% 5 37% 46% 6 35% 45% 7 39% 49% 8 41% 49% 9 35% 48% 10 39% 47% 11 39% 48% 12 36% 51% p = p <

9 What we know about HH Programs Compliance programs must be MULTIMODAL: Product at point of care Education Intervention Measurement & Feedback Patient Participation However, achieving significant and sustained improvement has been challenging.

10 HCW Psychological Factors: Spontaneous or Determinative Dr s Lounge

11 How do HCWs Think? We were trained to break down concepts into parts...but in complex systems like hand hygiene and health care delivery Relationships between parts are far greater than the parts alone. Carla J. Alvarado, PhD Research Scientist Emerita University of Wisconsin-Madison

12 HCWs Psychology and HH Applying psychological frameworks of behaviour change to improve healthcare worker hand hygiene: a systematic review Goal: To identify studies that used psychological theories of behaviour change to increase or predict hand hygiene compliance among HCWs. Theories: 1) Positive reinforcement 2) Change theory 3) Theory of planned behaviour 4) Transtheoretical model 5) Prediction studies based on the theory of planned behaviour, the transtheoretical model, and TDF J.A. Srigley, *, K. Corace b, D.P. Hargadon D. Yu a, T. MacDonald, L. Fabrigar G. Garber. Ontario JHI 2016.

13 Conclusion No theory produced significant and sustained increases Studies have used models that are best suited to explain deliberative behaviours. Hand hygiene is a repetitive, automatic behaviour and more of a habit. Hand hygiene is a spontaneous behaviour involving non-thoughtful behavioural responses. Habit theories stress the importance of establishing strong automatic associations between performance of a behaviour and cues at the time the behaviour is initially started and that these cues are present in the environment where the behaviour will later be performed What might these clues be??? Always there and always replaced. Provide education at time of performance.

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

15 Priming Hand Hygiene Compliance in Clinical Environments Priming in terms of psychology refers to the effects of some event or action on subsequent associated response Control group Two phases: olfactory (160) and visual (124) Control group: 15% HHC Olfactory: 46% HHC Visual: Male eyes: 33%; Female:10% HHC Top: Female Bottom: Male D., Vlaev, I., Everett-Thomas, R., Fitzpatrick, M., Darzi, A., & Birnbach, D. J. (2015, July 27). Priming Hand Hygiene Compliance in Clinical Environments. Health Psychology.Advance online publication

16 Theory of Obedience and Role Modeling Voice Prompts: ICU We want 100% HH Compliance in our ICU. Remember handwashing before and after patient contact. Gloves do not replace hand hygiene. Significant increase in hand sanitizer by HCW and visitor McGuckin M. The Effect of Random Voice Hand Hygiene Messages Delivered By Medical, Nursing and Infection Control Staff On Hand Hygiene Compliance In Intensive Care. AJIC. 2006

17 It s Not All About Me: Motivating Hand Hygiene Among Health Care Professionals by Focusing on Patients: Psychological Science 22(12) Personal Safety versus Patient Safety: Persuasion Theory Using Reminders of Patient Consequences HCW sign, Hand hygiene prevents you from catching diseases. The patient-consequences sign, Hand hygiene prevents patients from catching diseases. The control sign, which was developed by hospital managers, Gel in, wash out. The patient-consequences sign produced an increase of more than 45% in the amount of hand-hygiene product used per dispenser and an increase of more than 10% in HHC. Grant and Hoffman Management Department, The Wharton School, University of Pennsylvania, and 2Kenan-Flagler Business School, University of North Carolina at Chapel Hill

18 Patient Psychological Factors Patients should be sure that any Physician, Nurse, Therapist, has washed his/her hands before touching them. McGuckin, M., Medical World News,

19 27 Years Later!!!! "A process in which patients understand their role, are given the knowledge and skills by their health-care provider to perform a task in an environment that recognizes community and cultural differences and encourages patient participation. WHO Guidelines on Hand Hygiene in Health Care (2009) Health empowerment emphasizes facilitating one s awareness of the ability to participate knowingly in health and health care decisions.

20 Evidence That Empowerment Works Acute care - McGuckin, et al, AJIC 1999;27: McGuckin, et al, JOIC 2001;48: Acute Care Oxford, UK - McGuckin M. The Journal of Hospital Infection, 48: LTC - McGuckin, et al, The Director 2004,Vol 12;(1):14-17 Rehabilitation - McGuckin, et al, Am J Infect Control 2004;32:235-8 ICU - McGuckin, et al, Am J Infect Control Dec 2006

21 PIYC Empowerment Model Evaluation Year Location Source Impact 1997 US, multicenter McGuckin et. al. Patient Education Model for Increasing Handwashing Compliance. Am J Infect Control % HH/bd 1998 Oxford, UK McGuckin et. al. Evaluation of Patient Empowering Hand Hygiene Programme in UK. J Hosp Infec % HH/bd 1999 Norway 5 hospitals + 40% HH/bd 2000 Denmark 5 hospitals + 35% HH/bd 2001 Netherlands 2 hospitals + 50% HH/bd Germany 20 hospitals + 40% HH/bd 2002 Switzerland 2 hospitals + 45% HH/bd 2003 US rehabilitation hospital. McGuckin et. al. Evaluation of a Patient Education Model for Increasing Hand Hygiene Compliance in an In- Patient Rehabilitation Unit. Am J Infect Control % HH/bd 2005 Long Term Care McGuckin, et. al. Validation of a Comprehensive Infection Control Program in LTC The Director % HH/bd 2005 US McGuckin et al. Consumer attitudes about health care-acquired infections and hand hygiene. Am J Med Qual ICU McGuckin, et. al. The Effect of Random Voice Hand Hygiene Messages Delivered by Medical, Nursing, and Infection Control Staff on Hand Hygiene Compliance in Intensive Care Am J Infect Control % would ask + 100% sanitizer use HH/bd = Hand Hygiene occurrences per patient bed day

22 DO PATIENTS WANT TO BE EMPOWERED? National Telephone Survey U.S. 80% (4/5) respondents said they would ask their HCW to wash hands if encouraged by staff 52% respondents saw HCW put on gloves rather than practice HH McGuckin M, et al. Consumer Attitudes About Healthcare-Acquired Infections and Hand Hygiene. Amer Journal of Med Quality. 21:1-5, 2006

23 2007 Survey If your doctor, nurse or other person providing healthcare to you, DID NOT ASK or invite you to remind them to wash/sanitize their hands before examining you, would you feel comfortable asking them to wash/sanitize their hands? If your doctor, nurse or other person providing healthcare to you ASKED or invited you to remind them to wash/sanitize their hands before examining you, would you feel able to do this? If you saw your doctor or nurse taking care of the patient next to you and then coming to you without washing or sanitizing their hands, would you ask them to do so? 58.3% % % 86.9% YES 94.9% 84.8% 80.6% Overall USA Canada Overall USA Canada Overall USA Canada 90.5% 65.2%

24 Conclusion Most patients believe that they should be involved in hand hygiene 71% 29% Patients should not be involved Patients should be involved Source: National Patient Safety Agency

25 Willingness: Patients want Empowerment! 1989: Pay for IC information 1 Yes No Ask about HH 2 Yes No 2005: Involved in HH 3 Yes No 2006: Ask if given permission 4 Yes No 43% 57% 30% 70% 29% 71% 20% 80% These show intention, not action. Missing link: HCW explicit permission to ask Sources (left to right): 1) P.J. Miller, B.M. Farr. Survey of patients knowledge of nosocomial infections. Am J Infect Control 1989;17:31-4.; 2) McGuckin various studies, 3) National Health Service. National Patient Safety Guide Cleanyourhands campaign supporting resource 28 Staff Guide to Patient Involvement, 4) McGuckin M, Waterman R, Shubin A. Consumer attitudes about health care-acquired infections and hand hygiene. Am J Med Qual Sep-Oct;21(5):342-6.

26 Evidence for HCW Explicit Permission Study origin Patient believes he/she should be involved Patient would ask about hand hygiene Would Ask if HCW permission to patient England and Wales NPSA (2004) 1 71% 26% Not measured (N/M) Ontario (Canada) 2 32% 42% N/M USA consumer survey 3 N/M N/M 80% USA web survey 4 N/M 60% N/M World Health Organization survey 5 N/M 52% 86% UK 6 79% N/M N/M USA 7 91% 45% N/M UK 8 Significant increase Switzerland 9 N/M 33% 81% Australia 10 90% 40% N/M

27 HCW Explicit Permission to Patients How useful do you think the following interventions would be in encouraging hand hygiene? Results combined from patients, healthcare workers, and coordinators. (N=1115 participants) Pittet D, Panesar SS, Wilson K, Longtin Y, Morris T, Allan V, Storr J, Cleary K, Donaldson L. Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study. J Hosp Infect Apr;77(4):

28 Ask Me to Sanitize or Wash My Hands THE PSYCHOLOGICAL THEORIES OF INFLUENCE AND PERSUASION

29 A Review of Electronic Hand Hygiene Monitoring: Considerations for Hospital Management in Data Collection, Healthcare Worker Supervision, and Patient Perception Patient Perception on Electronic Devices: not much research. One study: Michaelse, Sanders, Zimmer, and Bump (2013) Flashing alerts worn by HCW versus brochure on admission on HAIs (93% liked alert versus 7% brochure) BUT 90% would not seek care from doctor that did not perform HH and 60% would not go to that hospital. McGuckin et al. Journal of HealtHcare ManageMent 60:5 SepteMber/october 2015

30 Consumer Awareness IF ONLY I KNEW

31 Consumer perceptions of healthcare associated infection and hand hygiene - a global survey Claire Kilpatrick, Director S3 Global Consultant to the World @WHO Dr. Maryanne McGuckin McGuckin Methods International Hosted by Jules Storr World Health Organization Sponsored by WHO Patient Safety Challenge Clean Care is Safer Care

32 Consumers and Health Care If consumers make decisions about their health care choices, would they consider hand hygiene/infection standards as part of this decision making? A telephone survey was conducted: N=1001 Ireland (n=250), India (n=251), Mexico (n=251) and Hong Kong (n=249), were surveyed The period of study was October 22-29, 2014

33 The majority of respondents surveyed believe that health workers clean their hands at the right times when treating or caring for patients. This belief is highest among those in Hong Kong, followed by India. 100% Health Workers Clean Hands at Right Times When Treating/Caring For Patients 80% 60% 80% 67% 53% 57% 40% Yes 20% 0% 20% 33% 47% 43% Hong Kong India Ireland Mexico A1: Do you think that health workers (e.g. nurses and doctors) in hospitals and other settings (for example, clinics) clean their hands at the right times when treating/caring for patients? (Hong Kong=249, India=251, Ireland=250, Mexico=251) No

34 The majority of those who believe health care workers clean their hands at the right time believe they do so all of the time, except among those in Ireland. In Ireland, the majority believe it s just some of the time. Health Workers Clean Hands at Right Time 100% 80% 60% 40% 61% 55% 44% 73% All of the time 20% 0% 56% 45% 39% 27% Hong Kong India Ireland Mexico Some of the time A2: Do you think that health workers are cleaning their hands at the right time? Base=Think health workers clean their hands at the right time (Hong Kong=200, India=167, Ireland=133, Mexico=143)

35 Those in India are most likely to have asked a health worker about clean hands with respect to a visit or treatment they were receiving. Those in Mexico are second most likely to have asked, followed by those in Hong Kong. Very few in Ireland have asked. Ever Asked Individual Health Worker About Clean Hands with Respect to Visit or Treatment Receiving 100% 80% 29% 55% 17% 40% 60% 40% 20% 71% 45% 83% 60% Yes No 0% Hong Kong India Ireland Mexico A4: Have you ever asked an individual physician (doctor), nurse or other health worker, or a health care organization (e.g. hospital or clinic) any questions about this subject of clean hands with respect to a hospital/clinic visit or treatment you were receiving? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

36 Responses to questions about health workers cleaning their hands at the right time were based on respondents own personal experience for at least seven out of ten. Significantly fewer responses were based on information from friends and relatives, and few were based on media. Responses Regarding Health Workers Clean Hands at Right Times Based On Own experience 70% 72% 80% 83% Information from friends and relatives 27% 31% 36% 46% What read in newspapers or other media Other 11% 17% 15% 9% 3% 2% 4% 3% Hong Kong India Ireland Mexico 0% 20% 40% 60% 80% 100% A3: Were your answers to the previous questions based on? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

37 When asked what they think happens if the hands of health workers are not cleaned at the right time before touching patients, more than four in five said that germs are spread to patients. Half said the health worker might get sick. Those in Hong Kong are least to think patients might be seriously harmed or even die, germs may spread to family members, or infections are passed on to patients. What Happens if Health Workers Hands Aren t Cleaned at Right Time Before Touching Patients Germs are spread to patients A nurse/other health worker might get sick 49% 49% 48% 50% 84% 85% 86% 86% Patients might be seriously harmed or even die 42% 51% 51% 49% Germs spread to family members 36% 42% 44% 47% Infections are passed on to patients Other 0% 3% 1% 2% 22% 36% 33% 48% Hong Kong India Ireland Mexico 0% 20% 40% 60% 80% 100% A5: What do you think happens if the hands of nurses/doctors/other health workers are not cleaned at the right time before touching patients? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

38 AWARENESS, ENGAGEMENT AND INTENT How the Consumer Uses These Actions Demographic Characteristics of Consumer Public Reporting of Health Care Associated Infection Rates Maryanne McGuckin, DrScEd, FSHEA, John Govednik, MS, David Hyman, JD, MD, Bernard Black, JD American Journal of Medical Quality Vol 29, Issue 1, pp : July

39 Consumer Results (Cont d) 1 P = P= P= P = P = P =

40 Consumer Results (Cont d) Awareness Engagement Intention Educ High Sch 32% 8% 58% College 40% 12% 50% Post Grad 47% 18% 47% More educ more aware 1 More educ more engaged 2 Inc <$25,000 30% 9% 60% $25-59,999 39% 12% 55% $60-99,999 41% 12% 48% $100, % 16% 43% More educ less intent 3 More income more Not significant 5 More income less aware 4 intent 6 1 P < P < P < P = P = P <

41 Consumer Results (Cont d) 1 P= P < P<0.0001

42 Persuasive Theory A FORM OF COMMUNICATION THAT AIMS AT MESSAGES THAT SUBTLY CHANGE THE ATTITUDE OF THE RECEIVER. Healthcare workers are empowered when they educate patients and invite them to ask questions Patients are empowered by participating in decisions helping to address medical errors Further reading: McGuckin M, Storr J, Longtin Y, Allegranzi B, Pittet D. Patient empowerment and multimodal hand hygiene promotion: a win-win strategy. Am J Med Qual Jan-Feb;26(1):10-7.

43 Steps of Persuasion Process As proposed by Professor Jay Conger, the following are the steps to be followed in the Persuasion Process: Step 1: Establish Credibility and Trust in Yourself Step 2: Find a Basis of Common Ground Step 3: Provide Vivid Proof Step 4: Connect at an Emotional Level Let us look at each in detail.

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

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

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

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

48 Conclusion: I Never Thought of it That Way! It is human nature not to believe something is possible if it doesn t fit into the current view. Our current view on HH compliance has become focused on technology and trying to show what does not work rather than focusing on human nature. Beyond Empowerment: Patients, Paradiggms, and Social Moveements. PSQH, Vol 13, Issue 2 April 2016

49 Are we Overthinking HHC? Two-step process: Quantitative and Qualitative 1.Quantitiative: Get HCWs to the sink/product at the right times THEN 2.Qualitative: Educate and monitor technique. Hand Hygiene Procedures

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