Psychological Factors

of Hand Hygiene

Presented by:

Dr. Maryanne McGuckin, FSHEA

Disclosure

Currently, McGuckin Methods International has a

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

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

products.

McGuckin Methods International

Mission: Pioneering effective methods for safe healthcare

delivery through research, education and advocacy.

Academic Career: Faculty of the University of Pennsylvania

Psychological Factors: 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.

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.

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

Healthcare Associated Infections (HAIs)

Cost: Total annual costs for the 5 major infections: $9.8 billion JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46.

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

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

N Engl J Med. 2014 Mar 27;370(13):1198-208

WHO Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection

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

Compliance in U.S.: MulticenterDespite overwhelming evidence that hand hygiene programs reduce

the spread of HAIs, compliance is at or below 50% - even after consistent

education, measurement and feedback.

MonthICU

Compliance

Non-ICU

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 = 0.0119 p < 0.0001

McGuckin M, Waterman R, Govednik J. Hand Hygiene Compliance in US. A Multicenter

Evaluation using Product Volume Measurement and Feedback. American Journal of

Medical Quality 24(3) 205-213 2009

What we know about HH 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.

HCW Psychological Factors:Spontaneous or Determinative

Dr’s Lounge

How do HCWs Think?

We were trained to break down concepts into parts...but in complex systems –

like hand hygiene and health care delivery

Relationships between parts are far greater than the parts alone

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

HCWs Psychology and 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 behaviourchange 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.

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.

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

“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 - 404

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

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.”

McGuckin M. The Effect of Random Voice Hand Hygiene Messages Delivered By

Medical, Nursing and Infection Control Staff On Hand Hygiene Compliance In

Intensive Care. AJIC. 2006

Significant increase in hand sanitizer by HCW and visitor

It’s Not All About Me: Motivating Hand Hygiene

Among Health Care Professionals by Focusing on

Patients: Psychological Science 22(12) 1494–1499

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

Patient Psychological Factors

“Patients should be sure that

any Physician, Nurse,

Therapist, has washed

his/her hands before

touching them.”

McGuckin, M., Medical World News,

2-15-82

27 Years Later!!!!

"A process in which patients understand their

role, are given the knowledge and skills by

their health-care provider to perform a task

in an environment that recognizes

community and cultural differences and

encourages patient participation.”

WHO Guidelines on Hand Hygiene

in Health Care (2009)

Health empowerment emphasizes facilitating one’s

awareness of the ability to participate knowingly in health

and health care decisions.

Evidence That Empowerment Works

Acute care - McGuckin, et al, AJIC 1999;27:309-14

McGuckin, et al, JOIC 2001;48:222-227

Acute Care Oxford, UK - McGuckin M. The Journal of Hospital Infection,

48:222-227 2001.

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

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

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

PIYC Empowerment Model Evaluation

1997-2006

Year Location Source Impact

1997 US, multicenter McGuckin et. al. Patient Education Model for Increasing Handwashing Compliance. Am J Infect Control 1999. + 34% HH/bd

1998 Oxford, UK McGuckin et. al. Evaluation of Patient Empowering Hand Hygiene Programme in UK. J Hosp Infec 2001. + 40% HH/bd

1999 Norway 5 hospitals + 40% HH/bd

2000 Denmark 5 hospitals + 35% HH/bd

2001 Netherlands 2 hospitals + 50% HH/bd

2001-2 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 2004.

+ 56% HH/bd

2005 Long Term Care McGuckin, et. al. Validation of a Comprehensive Infection Control Program in LTC The Director 2004. + 52% HH/bd

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

2006.

80% would ask

2006 ICU McGuckin, et. al. The Effect of Random Voice Hand Hygiene Messages Delivered by Medical, Nursing, and

Infection Control Staff on Hand Hygiene Compliance in Intensive Care Am J Infect Control 2006.

+ 100% sanitizer use

HH/bd = Hand Hygiene occurrences per patient bed day

DO PATIENTS WANT TO BE EMPOWERED?

National Telephone Survey – U.S.

80% (4/5) respondents said they would ask

their HCW to wash hands if encouraged by staff

52% respondents saw HCW put on gloves rather

than practice HH

McGuckin M, et al. Consumer Attitudes About Healthcare-Acquired Infections and Hand Hygiene. Amer Journal of

Med Quality. 21:1-5, 2006

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

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

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

YES

0

10

20

30

40

50

60

70

80

90

100

Overall USA Canada Overall USA Canada Overall USA Canada

58.3%

69.8%

47.8%

86.9%

94.9%

84.8%80.6%

90.5%

65.2%

Conclusion

Most patients believe that they should be involved

in hand hygiene

29%

71%

Patients should not be involved Patients should be involved

Source: National Patient Safety Agency

Willingness: Patients want Empowerment!

These show intention, not action.

Missing link: HCW explicit permission to ask

57%43%

1989:Pay for IC information1

Yes No

70%

30%

1999-2005Ask about HH2

Yes No

71%

29%

2005:Involved in HH3

Yes No

80%

20%

2006:Ask if given permission4

Yes No

Sources (left to right): 1) P.J. Miller, B.M. Farr. Survey of patients’ knowledge of nosocomial infections. Am J

Infect Control 1989;17:31-4.; 2) McGuckin various studies, 3) National Health Service. National Patient Safety

Guide Cleanyourhands campaign supporting resource 28 – Staff Guide to Patient Involvement, 4) McGuckin M,

Waterman R, Shubin A. Consumer attitudes about health care-acquired infections and hand hygiene. Am J Med

Qual. 2006 Sep-Oct;21(5):342-6.

Evidence for HCW Explicit Permission

Study originPatient believes he/she

should be involved

Patient would ask about

hand hygiene

Would Ask if HCW

permission to patient

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

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

USA consumer survey3 N/M N/M 80%

USA web survey4 N/M 60% N/M

World Health Organization survey5 N/M 52% 86%

UK6 79%N/M

N/M

USA7 91% 45% N/M

UK8 Significant increase

Switzerland9 N/M 33% 81%

Australia10 90% 40% N/M

HCW Explicit Permission to PatientsHow useful do you think the following interventions would be in encouraging

hand hygiene? Results combined from patients, healthcare workers, and

coordinators. (N=1115 participants)

Pittet D, Panesar SS, Wilson K, Longtin Y, Morris T, Allan V, Storr J, Cleary K, Donaldson L. Involving the patient to ask about hospital

hand hygiene: a National Patient Safety Agency feasibility study. J Hosp Infect. 2011 Apr;77(4):299-303.

Ask Me to Sanitize or Wash My Hands

THE PSYCHOLOGICAL THEORIES OF INFLUENCE AND PERSUASION

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

A Review of Electronic Hand Hygiene Monitoring:

Considerations for Hospital Management in Data Collection,

Healthcare Worker Supervision, and Patient Perception

Patient Perception on Electronic Devices: not much research.

One study: Michaelse, Sanders, Zimmer, and Bump (2013)

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

alert versus 7% brochure)

BUT90% would not seek care from doctor that did not perform HH

and 60% would not go to that hospital.

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

Consumer Awareness

IF ONLY I KNEW

Consumer perceptions of healthcare

associated infection and hand hygiene

- a global survey

Claire Kilpatrick, Director S3 Global

Consultant to the World Health Organisation

@safesafersafest @claireekt @WHO

Dr. Maryanne McGuckin

McGuckin Methods International

www.mcguckinmethods.com @drmcguckin

Hosted by Jules Storr

World Health Organization

Sponsored by WHO Patient Safety Challenge Clean Care

is Safer Care

www.webbertraining.com

Consumers and Health Care

If consumers make decisions about their health care choices,

would they consider hand hygiene/infection standards as

part of this decision making?

A telephone survey was conducted: N=1001

Ireland (n=250), India (n=251), Mexico (n=251) and Hong

Kong (n=249), were surveyed

The period of study was October 22-29, 2014

The majority of respondents surveyed believe that health workers clean

their hands at the right times when treating or caring for patients. This

belief is highest among those in Hong Kong, followed by India.

A1: Do you think that health workers (e.g. nurses and doctors) in hospitals and other settings (for example, clinics) clean their hands at

the right times when treating/caring for patients? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

20%33%

47% 43%

80%67%

53% 57%

0%

20%

40%

60%

80%

100%

Hong Kong India Ireland Mexico

Health Workers Clean Hands at Right Times When Treating/Caring For Patients

Yes

No

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.

39%45%

56%

27%

61%55%

44%

73%

0%

20%

40%

60%

80%

100%

Hong Kong India Ireland Mexico

Health Workers Clean Hands at Right Time…

All of thetime

Some of thetime

A2: Do you think that health workers are cleaning their hands at the right time…? Base=Think health workers clean their hands at the

right time (Hong Kong=200, India=167, Ireland=133, Mexico=143)

Those in India are most likely to have asked a health worker about clean

hands with respect to a visit or treatment they were receiving. Those in

Mexico are second most likely to have asked, followed by those in Hong

Kong. Very few in Ireland have asked.

A4: Have you ever asked an individual physician (doctor), nurse or other health worker, or a health care organization (e.g. hospital or

clinic) any questions about this subject of clean hands with respect to a hospital/clinic visit or treatment you were receiving? (Hong

Kong=249, India=251, Ireland=250, Mexico=251)

71%

45%

83%

60%

29%

55%

17%

40%

0%

20%

40%

60%

80%

100%

Hong Kong India Ireland Mexico

Ever Asked Individual Health Worker About Clean Hands with Respect to Visit or Treatment Receiving

Yes

No

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.

3%

9%

31%

80%

4%

15%

27%

72%

2%

17%

46%

83%

3%

11%

36%

70%

0% 20% 40% 60% 80% 100%

Other

What read in newspapers or other media

Information from friends and relatives

Own experience

Responses Regarding Health Workers Clean Hands at Right Times Based On…

Hong Kong

India

Ireland

Mexico

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

When asked what they think happens if the hands of health workers are

not cleaned at the right time before touching patients, more than four in

five said that germs are spread to patients. Half said the health worker

might get sick. Those in Hong Kong are least to think patients might be

seriously harmed or even die, germs may spread to family members, or

infections are passed on to patients.

2%

33%

47%

49%

50%

86%

1%

48%

44%

51%

48%

86%

3%

36%

42%

51%

49%

85%

0%

22%

36%

42%

49%

84%

0% 20% 40% 60% 80% 100%

Other

Infections are passed on to patients

Germs spread to family members

Patients might be seriously harmed or even die

A nurse/other health worker might get sick

Germs are spread to patients

What Happens if Health Workers’ Hands Aren’t Cleaned at Right Time Before Touching Patients

Hong Kong

India

Ireland

Mexico

A5: What do you think happens if the hands of nurses/doctors/other health workers are not cleaned at

the right time before touching patients? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

AWARENESS, ENGAGEMENT AND INTENT

How the Consumer Uses These Actions

Demographic Characteristics of Consumer

Public Reporting of Health Care–Associated Infection Rates

Maryanne McGuckin, DrScEd, FSHEA, John Govednik, MS, David Hyman, JD, MD, Bernard Black, JD

American Journal of Medical Quality

Vol 29, Issue 1, pp. 83 – 85: July-23-2013

Consumer Results (Cont’d)

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

Consumer Results (Cont’d)

Awareness Engagement Intention

Educ High Sch 32% 8% 58%

College 40% 12% 50%

Post Grad 47% 18% 47%

More educ more aware1

More educ more engaged2

More educ less intent3

Inc <$25,000 30% 9% 60%

$25-59,999 39% 12% 55%

$60-99,999 41% 12% 48%

$100,000+ 46% 16% 43%

More income more aware4

Not significant5 More income less intent6

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

Consumer Results (Cont’d)

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

Persuasive Theory

Healthcare workers are empowered

when they educate patients and

invite them to ask questions

Patients are empowered by

participating in decisions helping to

address medical errors

Further reading: McGuckin M, Storr J, Longtin Y,

Allegranzi B, Pittet D. Patient empowerment and

multimodal hand hygiene promotion: a win-win

strategy. Am J Med Qual. 2011 Jan-Feb;26(1):10-7.

A FORM OF COMMUNICATION THAT AIMS AT

MESSAGES THAT SUBTLY CHANGE THE

ATTITUDE OF THE RECEIVER.

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

followed in the Persuasion Process:

• Step 1: Establish Credibility and Trust in Yourself

• Step 2: Find a Basis of Common Ground

• Step 3: Provide Vivid Proof• Step 4: Connect at an Emotional Level

Let us look

at each in

detail.

Step 1: Establish Credibility and Trust in 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.

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.

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.

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.

Conclusion: “I Never Thought of it

That Way!”

It is human nature not to believe something is possible if

it doesn’t fit into the current view.

Our current view on HH compliance has become focused

on technology and trying to show what does not work

rather than focusing on human nature.

Beyond Empowerment: Patients, Paradiggms, and Social Moveements.

PSQH, Vol 13, Issue 2 April 2016

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

1.Quantitiative: Get HCWs to the sink/product at the right times

THEN

2 .Qualitative: Educate and monitor technique.

Hand Hygiene Procedures

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