Hand Hygiene and Behavior Change

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Andreas Voss Andreas Widmer

Sbarbaro Clin Infect Dis 2001,33:S240

Changing physicians behavior is considered by many to be an exercise in fuHlity – an unaJainable goal intended only to produce premature aging in those seeking the change. The more opHmisHc might describe the process as uniquely challenging.

= coordinated set of acHviHes designed to change specified behavior paJern

… and that you are Dutch

Lets assume that you are interested in hand hygiene …

By far the lowest

observed %

published

compliance with

HH

¤ 24 hospitals in the NL (ICUs & surgery)

¤ 19% overall compliance

² 3% before ² 22% a]er

¤ No difference between RN en MD

¤ Smaller hospitals beJer than bigger

Vicky Erasmus Inf Control Hosp Epidemiol 2009 The Lowlands (NL)

21%

The Honestlands

50-‐70%

The Lielands

80-‐95%

The Rest of the World

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hJp://www.hha.org.au/LatestNaHonalData.aspx

¤  We look, others don’t … ¤  Our surveillance is too good (no Hawthorne effect) …

¤  No one can do beJer … ¤  Five indicaHons are (two) too many …

¤  Handhygiene is only one of the measures …

¤  EducaHon ¤  IncenHves for appropriate behaviour ¤  Penalise inappropriate behaviour ¤  …. ¤  No target behavior analysis ¤  No theory on predicted mechanism of acHon ¤  Not considering impulsivity, habit, self-‐control, associaHve learning, …

Standard approach

¤  First canvas the full range of opHons available ¤  Second raHonal selecHon from them

²  to match the behavioral target, the target populaHon and the context in which in which intervenHon will be delivered

Improvedapproach

Michie et al. ImplementaHon Science 2011;6:42

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Individual’s psychological & physical capacity to engage in the acHvity concerned. Having knowledge & skills

Michie et al. ImplementaHon Science 2011;6:42

Brain processes that direct behavior:

conscious decision making, emoHnal responding, habits

Factors that lie outside the individual that make behavior possible or

prompt it

``````

```````````

This model of behavior allows designing interven4ons

Michie et al. ImplementaHon Science 2011, 6:42



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A wise man that you shouldn't mix it in the fruit salad.

A smart man knows that a tomato is a fruit.

… but the fact that I don’t like tomato in my fruit salad doesn’t mean that I am wise!

“Diffusion is the process in which an innovaHon is communicated through

certain channels over Hme among the members of a

social system”

Slides on diffusionin part from Sara Gossgrove

¤ Rela4ve advantage ² Is it beJer than what we already have according to the users (not you)?

¤ Compa4bility ² Is it consistent with exisHng values and pracHces?

¤ Simplicity/ease of use ² Is it easy to understand/adopt?

¤ Trialability ² Can the innovaHon/change be experimented with on a limited basis?

¤ Observability ² Can users see the results of the innovaHon/change?

¤ Categories of adopters ² Innovators (2.5%) ² Early adopters (13.5%) ² Early majority (34%) ² Late majority (34%) ² Laggards (16%)

The diffusion curve generally takes off a]er 10-‐20% adopHon

Not for HH

¤  PercepHon Failures CommunicaHon Failures ¤  Engagement Failures ¤  LogisHcal Failures

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¤ Those non-‐compliant don’t believe the evidence or think their situaHon is different

¤ What can you do? ² Repeated conversaHons

² Face-‐to-‐face preferred ² Show data that non-‐compliance harms paHents Address message to all levels of physicians (trainees to clinical leadership)

² Show that your recommendaHons are similar to those from other similar insHtuHons (peer-‐pressure)

¤  RecommendaHons are too complex or we sound doubrul

¤  What can you do? ²  Make a single recommendaHon or provide no more than two opHons ² Avoid decision paralysis

²  Be confident ²  Be enthusiasHc

decision paralysis

¤ Don’t care about hand hygiene ² Involve teams in making local guidelines

² Feedback observaHons and provide posiHve reinforcement

² Appeal to emoHons ² Cases of real paHents who were harmed

² Evidence that the individual paHent can be harmed

¤  Missing means to disinfect hands or reinforce compliance ²  sufficient dispensers and availability at point-‐of-‐care

²  Talking walls/reminders

¤  Missing feed-‐back ¤  Not involving KOL’s

¤ While we wish to make the most thoughrul, fully considered decision possible … we frequently resort to comply on basis of a single piece of informaHon (trigger)

¤ “Click-‐whirr” (automaHc response, fixed acHon paJern)

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¤ Commitments

¤ OpportuniHes for reciprocaHon

¤ Compliant behavior of similar others

¤ Feelings of liking & friendship

¤ Authority direcHves

¤ Scarcity informaHon

¤ Shortcuts – judgmental heurisHcs

¤ Contrast principal

¤ Consistency

Shortcuts-‐ contrast -‐ consistency

¤ “Expensive = good” (and opposite) ¤ “If an expert said so, it must be true”

² Airline industry “captainiHs”


¤ Perceptual contrast

² Buying suite and sweater à expensive item first

² Selling the car first, than the opHons



¤ Most people have a strong desire to look consistent within their words, beliefs, autudes

¤ Whenever one takes a stand that is visible to others, there arises a drive to maintain that stand in order to look like a consistent person.

¤ Therefore, wriJen-‐down and publicly made commitments can be used to influence others and ourselves


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¤ At the beach

² Leaving a blanket with valuables – pretended the] – 4/20 people in the area reacted

² Saying “watch my things” first à 19/20 reacted

If I can get someone to commit (take a stand or go on record) I can set the stage for automaHc consistency !

¤ QuesHon to home owners – place large billboard “Drive Carefully” in your lawn

¤ Two groups: A) 17% complied B) 76% complied

¤ Why the difference between A and B ? B was asked a few weeks before to display a small 3x3in sign in window “Be a safe driver”


¤ Key-‐person as role-‐models ¤ Published list of supporters

²  WHO pledge

¤ Pre-‐prime your customer ² Would you (theoreHcally) be supporHng our goals? Followed by a visit to commit them to IC


www.sciencexpress.org / 20 November 2008 / Page 1 / 10.1126/science.1161405

§  Orderly alley: 33% liJering §  GraffiH alley: §  69% liJering

¤ when people observe inappropriate behavior, this weakens their concern for appropriateness

§  Orderly alley §  No graffiH sign §  Flyer on handlebar §  avoid liJering

We need “order” in our hospitals and people showing appropriate behavior !

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¤ “we are obligated to future repayment”

¤ Regan et al. “Coke experiment”

² Joe gave others (unasked for) a drink. Later asked them to buy raffle Hckets from him à those who got a Coke bought more Hckets à those who “liked” Joe bought more Hckets

² but …. relaHonship between “liking” and compliance wiped out in those that received a Coke !

“a feeling of indebtedness by doing us an uninvited favor” ReciprocaHon

¤ Mailing a $5 gi] along with a survey was twice as effecHve as a $50 payment for sending it back (James & Bolstein 1992)

¤ à a small iniHal favor can produce a sense of obligaHon to agree to a larger return favor, since most of us find it highly disagreeable to be in a state of obligaHon

ReciprocaHon

¤ Reciprocal concessions

² Boy scout selling $5 Hckets for Saturday night event, when rejected offering $0,50 candies (buyer feels that second request is a concession to him)

¤ Rejec4on-‐then-‐retreat strategy

² Over ask first, than come with intended amount

² Ask volunteers for 1 week of community service than ask for 1 hour

ReciprocaHon

A nice Christmas gi] for your HCWs –

shortly before launching

your HH campaign

ReciprocaHon

¤ Principle of Social Proof ² Important means that people use to decide what to believe or how to act is to look what other believe or do

¤ Social proof is most influenHal under two condiHons ² Uncertainty ² Similarity

Similar others/social proof

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¤ “We view behavior as correct to the degree we see other performing it” ² When lots of people do it – it must be right

¤ Social proof is most influenHal under two condiHons ² Uncertainty ² Similarity

¤  Similar others/social proof

¤ Laughing tracks ² Others laugh = it must be funny

² we react to the sound (even if fake) – not the content

² works even if the sound is arHficial ¤ Church usher salHng collecHon baskets ¤ InvenHon of shopping carts (S. Goldman 1934)

² Shoppers stopped shopping when basket full ² First shopping carts not used ² Hire fake shoppers using carts throughout the shop ?


Similar others/social proof Asch conformity experiments

Uncertainty Heart aJack or drunk? Other bystanders reduce personal responsibility


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¤ Never again start a lecture with only 40% disinfect their hands … ² “all HCW agree that HH is the most important …”


¤ “ We most prefer to say YES to the request of people we know and like”

¤ Factors leading to liking: ² physical aJracHveness (halo effect) ² similarity ² familiarity ² praise ² associaHon

Liking

¤ Occurs when a one posiHve characterisHc of a person dominates the way a person is viewed

² Good-‐looking = talent, kind, honest, intelligent

² Works in many situaHons: even judicial process à handsome men lighter sentences

Liking

¤ “We like people that are similar to us” ² more likely to help those that dress like us

Liking

Familiarity

•  “Increases through repeated contact under posiHve circumstances”

•  “We are phenomenal suckers for flaJery” –  PosiHve comments produce just as much liking for the flaJerer independent if they were untrue or true

•  “Teamspirit” –  Car salesperson baJling with his boss to give us a good price

– Good Cop/Bad Cop

Liking

¤ The nature of the bad news infects the teller even when the person did not cause the bad news ² Blame the weatherman

Liking

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¤ An innocent associaHon with either bad or good things will influence how people feel about us or a product ² The good looking models next to the car ² RaHng of idenHcal car changed with and without model

² Men didn’t believe that their judgment was influenced

Liking

¤ Pavlov ² Normal response to food: salivaHon, good and favorable feeling ² AJach that feeling to any goal

² “luncheon technique” (ask during or a]er meal) ² Subjects become fonder of people and things they experienced while eaHng

Liking

¤ Praise instead of criHcize ! ¤ Let others report about the outbreak & extra measures

¤ InfecHon Control luncheon

Liking (aJracHveness, praise, familiarity, similarity, associaHon)

¤ Air freshener ² Will be using it in cars of nursing home MD’s as part of an HH improvement project

Liking (aJracHveness, praise, familiarity, similarity, associaHon)

Would love to have them at doors to

paHent’s room

¤ Power of authority (Milgram study, 1974)

¤ Symbols of authority ² Titles ² Clothing ² Automobiles

Authority

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Authority

Expert/Authority

¤ Various types of HCWs understanding their level of the job

¤ No one may overrule a doctor’s judgment à automaHc obedience to doctors’ order ² MD order for paHents with earache: “place in R ear”

² Neither nurse no paHent quesHon the rectal treatment of the earache

¤ People don’t consider the situaHon as a whole but aJend or respond to only one aspect of it

Authority

¤ TV commercial featuring Robert Young (not a medical authority) warning people against the danger of caffeine and recommending caffeine free coffee

¤ RY is associated in the mind of the US public as trusted Marcus Welby, MD from a long-‐running TV series

Authority

¤ Appearance of authority is enough to get is into the click,whirr mode

¤ Symbols of authority ² Titles ² Clothes ² Trappings

Authority

¤ PresHgious Htles lead to height distorHon ² Visitor to college presented as “Student” to “Professor” at 5 different levels, college students than asked to esHmate length: Δ 0.5 per category or 2.5 in overall

² Size and status is related

Authority Germany Netherlands

How high? No! Why? Yes … but I stay put

Authority (Voss, not in book)

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¤ Motorists wait significantly longer before honking their horns when stopped in front of a green light behind a luxury car versus an older economy model

¤ True for all symbols of authority: people grossly underesHmate the effect of authority influence on themselves

Authority

¤ People assign more value to opportuniHes when they are less available ² “limited number” and “deadline”

² Difficult to get = valuable

² Loosing freedom of choiceà increases wish

¤ Psychological reactance

¤ Scarcity and informaHon

scarcity, censorship, reactance

¤ Announce a limitaHon of hand-‐rub and than find a “new source of supply”

Authority (obedience, Htle,clothing, cars)

¤ “Things that are difficult to get are beJer” ¤ When free choice is limited or threatened the need to retain our freedom makes us want them significantly more ² “Terrible two and equally desirable toys of which one behind a Plexiglas barrier

² Parental interference with young love


¤ Response to “banned” informaHon ² Want the informaHon even more ² Believe the informaHon more even though it wasn’t received


¤ University undergrads’ wish to read a novel a]er 2 different ways of presentaHon …

Restricted t

o those of

21 years and

older

Zellinger 1974

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¤ Taste & rate cookies from jar ² jar with 10 cookies ² jar with 2 cookies (scarcity -‐> rated more favorably)

scarcity, censorship, reactance scarcity, censorship, reactance

¤ University HCWs’ wish to read CDC IC guidelines a]er 2 different ways of presentaHon …

Restricted t

o those

highly educa

ted

Limited Edition

Exclusive for HCWs

Where you wondering why the handouts are

so scarce?

¤ IntroducHon of new hand-‐rub or catheters in your hospital ² Present & announce, restrict it to ICU and those units that first order


Health & Medicine

Hand Hygiene and Behavior Change