Hand hygiene is the simplest and most effective, proven method to reduce healthcare associated infections and thanks to Ignaz Semmelweis, we have known so for over 150 years. Unfortunately, hand hygiene compliance it not a simple matter of education. In fact hand hygiene is thought of as boringly simple, not rocket science. It is precisely this attitude of smug familiarity dismissiveness that in part, undermines compliance. The fact is that improving compliance is perhaps more akin to brain surgery.
Investigators involved in studying how to improve hand hygiene compliance often with dismal results, usually postulate that we need to better understanding behavior theory. With these rumblings, I decided to look into studies that included what are considered the key components of behavioral change, education, attitude, and intent.
In examining behavioral surveys, I found that the educational background providing base knowledge leading to the decision to clean hands was quite high, in the 80% to 100% range. Thus it’s a slam-dunk that virtually all health care professionals have the requisite knowledge. The same surveys found that attitude regarding hand hygiene was also very high from 95% to 100%.
People really want to do the right thing and wash hands when situations demanded. Intent to wash hands was also fairly high but again slipping slightly to the 55% to 85% level, but still very encouraging. When asked to self report hand hygiene events these people participated in recently, there was again a slight drop but still in the 60% to 80% range, nothing to be alarmed about. But when we actually observed these populations in the same situations they knowledgably answered questions about, compliance were only seen to be in the 25% range at best. Thus, it is neither education nor attitude that seem to drive improvement in compliance.
A wide variety of different interventions have been studied in an effort to improve this practice. Various studies examining the relationship between hand hygiene compliance increases and nosocomial infection rates after hand hygiene campaigns have shown no improvement or only low-level efficacy. In many instances, effective and encouraging campaign results also lead to rapid reversion back to old habits. This gets in the way of meaningful progress, as hand hygiene training is quickly unlearned. The problem is that campaigns are, by definition, of short duration, and once the “hoopla” is over, “it’s business as usual”.
My work has shown that compliance for it’s own sake doesn’t deliver anywhere near the same punch as compliance targeting reduction in infection rates. It stands to reason that hand hygiene is not an end in itself but a means to an end, so we really need to focus on that end and consider hand hygiene, just one of the several tools (Hand Hygiene Alone Isn’t Enough). And who said we were ever going win the war against germs, (other that the US Surgeon General in 1969) in which it has been an uneasy truce during the entire existence of our species.
No single strategy has consistently been shown to sustain improved compliance with hand hygiene protocols. In addition, any intervention must target reasons for non-compliance at all levels of healthcare (i.e., individual, group, institution) in order to be effective. It is only with multifaceted programs, involving application of social marketing theory where effective improvements resulting in infection rate reduction occur. This often involves policy changes including rewards and punishments, equipment improvements, process improvements, and enhanced understanding (not just education).
Obtaining results at both compliance and infection rate improvement, it is not education, attitude or intent but instead like that great student of human behavior; P.T. Barnum puts it, "This Way to the Egress". Facility, product or process improvements can be used as “teachable moments” to shape behavior changes. When education and motivation are combined at the level of unconscious competence and it permeates an organizational culture committed to continuous process improvement with the proper use of available real estate, for placement of necessary hygiene facilities and supplies, it can maximize hand hygiene effectiveness and reduce infection rates in a seamless flow that would make P.T Barnum proud. Now that’s the trick.
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