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Where There’s A Will, There’s A Way

Jason Tetro
September 01, 2015

ThinkstockPhotos-177799104.jpgThe practice of hand hygiene is absolutely necessary to prevent the spread of infections. Yet, this potentially lifesaving procedure continues to be left out of the minds of many a healthcare worker. Making the situation worse is the unexpected challenge presented when attempting to improve frequency.


In light of the difficulties, many researchers have ventured into a different realm – psychology – to understand the reasons underlying resistance to change. A plethora of possible problems has been proffered, usually with interesting terms attached. Some of the more intriguing are: system gaps, institutional climate, goal and reward incentives, unit accountability, and human factors.


All of these definitions are valid in their own right and have shown their influence on hand hygiene compliance. Yet, to those have not chosen to read associated papers or position statements, the terms may be misconstrued as abstract jargon with little relevance to one’s personal situation. It’s a common issue in developing strategies to improve a population-based concern. A globally observed problematic phenomenon has little or no meaning to the individual. This spells trouble for any intervention as it may reach some but will definitely not reach all leading to missed benchmarks or worse, complete failure.


There is an answer that may offer a direction forward. Instead of looking at each of these individual global issues as separate from one another, examine the common denominator shared by all. Take out all of the systematic parameters and hone in on the one piece of human existence missing from the equation. You will eventually find the answer.


It’s will.


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Will is one of the most powerful psychological phenomena in human life. It can drive people to reach beyond their usual capacity and make significant changes to their lives. The personal drive can also be infectious, prompting others to align their intentions in a similar manner.


But there’s a dark side to this powerful force. A resistant will can negate the influence of any positive strategy. If interventions are seen as interference, no amount of convincing, whether through reward or threat, can force a person to budge. Even if actions are taken to comply with the implemented changes, they will be done begrudgingly and only last for a short while.


There’s the rub for hand hygiene compliance. To improve the overall situation, global interventions are necessary but they have to speak to the will of the individual. That is obviously no easy task and at first glance of the options, no strategy seems to be effective.


Yet, a recent systematic review and network meta-analysis in the British Journal of Medicine suggests one does exist and has been underneath our noses for over a decade. Based on the results of their examination into hand hygiene compliance, a simple human-focused campaign coming from the World Health Organization appears to be the right way to promote positive will.


The review looked at studies from 1980 to 2014 in the hopes of finding studies focused on improving hand hygiene; 41 met the criteria for inclusion. Of those, many focused on changing various aspects of will such as system change, education, reminders, safety climate, incentives, goal setting, and accountability. Alongside these were studies using the WHO’s Patient Safety Challenge. The strategy comprised of a motto, “Clean Care is Safer Care,” and the dissemination of a practice called the “Five Moments for Hand Hygiene.”    


The results were incontrovertible. The WHO option was by far the best at improving hand hygiene compliance. The campaign was also an excellent foundation upon which other interventions could be included. When this happened, the compliance increased even further. In comparing a single intervention against the same one grouped with the WHO campaign, the chance for improvement nearly tripled. The improvements were also sustained over a year after initiation. This result could have been due to the evergreen nature of the worldwide campaign. Essentially, there was no end to the momentum. This continued the influence and maintained positive will over the long term.  


The results of this review reveal human will as the most important factor in any hand hygiene intervention strategy. Without reinforcing a positive personal drive, any effort may work in the short term but may fail due to lack of sustainability. Based on this study, the WHO program seems to have found the right niche and may offer a cost-effective option either alone or in concert with another intervention. All that’s needed it seems, is the will to adopt it.


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