W. H. !&to, MD T. Y. Ching, RN Y. B. Chu, BSc W. L. Seto, MA Hong Kong and Champaign,
Illinois
In the prevention of nosocomial infection it is important to understand its epidemiology and pathogenesis. Only then are we able to formulate policies that are effective in the prevention of these infections. However, implementation of these policies can be extremely difficult, because hospital staff may not comply with them.’ The study of hospital staff compliance is therefore vital in the practice of infection control. To understand compliance, it is worthwhile to investigate the role of social power in infection control. Social power is defined as the potential ability of an influencing agent to change the cognitions, attitudes, or behavior of another person (the target).’ The pioneers in the study of social power in infection control were the workers in the Study on the Efficacy of Nosocomial Infection Control (SENIC) project.‘, ’ These workers investigated the compliance of nurses with infection control policies when the six bases of social power (see Methods for definitions), first described by French and Raven,3 were used. However, the study has never been replicated outside the United States and the imFrom the Department of Microbiology, University of Hong Kong, Infection Control Unit, Queen Mary Hospital, and Institute of Communication Research, University of Ninois. Wing Hong Seto, MD, Department of Microbiology, University of Hong Kong, Queen Mary Hospital, Hong Kong. 17/47/2on58
42
pact of social power on other categories of hospital staff has never been investigated. Therefore, using the six bases of power, we conducted in Hong Kong a study comparing the motivation for compliance with infection control policies by nurses and housekeeping staff (H-KS).
The study was conducted in Queen Mary Hospital (QMH), a 1310-bed teaching hbspital in Hong Kong. For the six bases of power, the following SENIC definitions2 were adopted in the study: 1. Coercive power: Stems from the ability of the influencing agent to mediate punishment for the target 2. Reward power: Stems from the ability to mediate rewards 3. Legitimate power: Stems from the target’s acceptance of a role relatiuaship with the agent that obligates the target to comply with the agent’s request 4. Expert power: Stems from the target’s attribution of superior knowledge or ability to the agent 5. Referent power: Stems from the target’s utilization of others as a “frame of reference” to evaiuate his orher behavior 6. Informational power: Stems from the persuasiveness of the information communicated by the agent to the target . QMH employs a total of 4%) HKS
Volume 19 Number 1
Staff compliance with infection control policies
February 1991
43
Table 1. Reports of nurses and housekeeping staff on the power base that will most likely secure compliance to infection control policies Hong Kong*
Power base Coercive Reward Legitimate Expert Referent Informational ‘Differences between a and b are significant by chi-square with Yates correctIon. tSee reference 2.
No. of staff nurses (%) (n = 142) a
No. of HKS (%) (n = 140) b
1 (O.Ol),
11 12 42 30 12 33
8 (5% 10 40 4 79
(7.0), (28.2), (2.8)8 (55.6),
(7.9), (8.6), (3Oh (21 .4)8 (8.6), (23.6),
@ < 0.001, x2 = 53 1). Groups in the same row with different subscripts
and 1400 staff nurses. With the use of a random numbers table, a random sample of 150 HKS and a stratified random sample of 150 nurses, proportional to the rank distribution in the hospital, were selected. Survey on staff compliance. The subjects were personally interviewed by the three infection control nurses (ICNs) in the hospital during November 1987. According to the sequence in Table 1, respondents were first given these definitions for the six bases of power, both orally and in writing, and then the following instruction: “A new policy that is appropriate for preventing infection is introduced by the ICN. Which power base would most likely secure your compliance with the policy?” The survey was completed within 2 weeks. RESULTS
A total of 142 nurses and 140 HKS were interviewed, whereas 18 subjects were either on leave or had resigned. Among the nurses were 25 students (18%) 12 licensed vocational nurses (8%), 95 registered nurses (67%) and 10 head nurses (7%). The majority were women (89%), and the mean duration of service in the hospital was 5 years. For the HKS 71% were women and the mean duration of service was 11 years. The responses in the survey are shown in Table 1, which includes the results of the SENIC study for comparison. 2 As shown, the highest responses reported by the nurses in both studies were for expert and informational power. How-
% of U.S. staff nurses (SENIC)t (n = 7069) 0.3 0.1 2.1 56.1 4.4 36.9 differ significantly
@ < 0.05)
ever, unlike the SENIC result, the response reported for informational power in: this study (56%) was higher than that of expert power (28%).
In this study the responses reported by the HKS differed significantly (p < 0.001, x2 = 53) from that of the nurses. For the nurses the response reported for informational power (56%) was the highest and this was significantly higher (p < 0.001, x2 = 28.9) than the 24% for the HKS. On the other hand, the highest response reported by the HKS was for legitimate power (30%) and this was significantly higher (p < 0.001, x2 = 23.2) than the 7% for the nurses. In both groups the response to expert power was fairly high (28% for nurses, 21% for HKS) and no significant difference was noted between them (p = 0.24, x2 = 1.37). The response to coercive power was the lowest for both groups, and the response reported by the HKS (8%) was significantly higher (p < 0.01, x2 = 7.1) than the nurses (0.01%). DISCUSSION
Social power and influence occupy a central place in organizational and social psychology research4 but is a neglected area in infection control.’ A recent review4 identified 18 separate studies in the literature that used the French and Raven bases of power for research, and none was related to infection control. The SENIC report* is the only study that applied
Amertcan Journal of
44
Set0 et al.
INFECTION CONTROL
the bases of power to the field of infection control. Strict comparison between the results of SENIC and this study is not possible, because there is no evidence that the two samples of nurses are comparable. Nevertheless, both studies do show that for nurses the best responses are for informational and expert power. Therefore ICNs should exercise these powers when they are trying to influence their colleagues with regard to infection control. As suggested by Haley et al., 5 this should include the provision of “relevant references and convincing information,” including local surveillance data. The response to expert power reported by nurses in this study was less than that in SENIC. This could be related to the short history of infection control in Hong Kong; ICNs were deployed at QMH only in July 1985 and consequently their status as infection control experts was not as established as in the United States. A significant finding in this study is the differences in response between HKS and nurses. This is not altogether unexpected, because the two groups are different in many aspects, including educational background, age, and sex ratio. However, it would be important for ICNs in Hong Kong to realize that HKS are more responsive to legitimate and coercive power and less to informational power. Therefore, to
influence the HKS, it would be advantageous to present the request as coming from a legitimate superior; in addition, evidence of their supervisor’s endorsement should always be shown. Besides social influence, the findings in this study should also be highly relevant for hospital staff education. In the education of nurses, the quality and type of information is probably crucial and the teacher should be proficient enough to come across as an expert. On the other hand, for the HKS the teacher can probably be more dogmatic. It would be crucial for the teacher to show that the education program has been fully approved by the hospital administration. Refwenoes 1. Raven BH, Haley RW. Social science perspective in hospital infection control. In: Johnson AW, Grusky 0, Raven BH, eds. Contemporary health services: a social science perspective. Boston: Auburn House, 198 1: i39-75. 2. Raven BH, Haley RW. Social influence and compliance of hospital nurses with infection control policies. In: Eiser RJ, ed. Social psychology and behavioral medicine. New York: John Wiley, 1982:413-38. 3. French JRP, Raven BH. The bases of social power. In: Cartwright D, ed. Studies in social power. Ann Arbor: University of Michigan, 1959:150-67. 4. Podsakoff PM, Schriesheim CA. Field studies of French and Raven’s bases of power: critique, reanalysis, and suggestions for future research. PsycholBull 1985;97: 387-411. 5. Haley RW, Aber RC, Bennett JV. Surveillance of nosocomial infection. In: Bennett JV, Brachman PS, eds. Ho+ pita1 infections. 2nd ed. Boston: Little Brown & Co, 1986:51-71.
r-
Bound volumes available to subscribers Bound volumes of AMERICANJOURNALOFINFECTIONCONTROLare available to subscribers (only) for the 1991 issues from the Publisher, at a cost of $19.00 ($25.00 international) for Vol. 19 (January-December). Shipping charges are included. Each bound volume contains a subject and an author index. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318, USA; phone 800-325-4177, ext. 4351.
Subs&ptions must be in force to qualify, Bound volumes are not avatlobk of a regular journal subscription.
in plplw
Illinois
In the prevention of nosocomial infection it is important to understand its epidemiology and pathogenesis. Only then are we able to formulate policies that are effective in the prevention of these infections. However, implementation of these policies can be extremely difficult, because hospital staff may not comply with them.’ The study of hospital staff compliance is therefore vital in the practice of infection control. To understand compliance, it is worthwhile to investigate the role of social power in infection control. Social power is defined as the potential ability of an influencing agent to change the cognitions, attitudes, or behavior of another person (the target).’ The pioneers in the study of social power in infection control were the workers in the Study on the Efficacy of Nosocomial Infection Control (SENIC) project.‘, ’ These workers investigated the compliance of nurses with infection control policies when the six bases of social power (see Methods for definitions), first described by French and Raven,3 were used. However, the study has never been replicated outside the United States and the imFrom the Department of Microbiology, University of Hong Kong, Infection Control Unit, Queen Mary Hospital, and Institute of Communication Research, University of Ninois. Wing Hong Seto, MD, Department of Microbiology, University of Hong Kong, Queen Mary Hospital, Hong Kong. 17/47/2on58
42
pact of social power on other categories of hospital staff has never been investigated. Therefore, using the six bases of power, we conducted in Hong Kong a study comparing the motivation for compliance with infection control policies by nurses and housekeeping staff (H-KS).
The study was conducted in Queen Mary Hospital (QMH), a 1310-bed teaching hbspital in Hong Kong. For the six bases of power, the following SENIC definitions2 were adopted in the study: 1. Coercive power: Stems from the ability of the influencing agent to mediate punishment for the target 2. Reward power: Stems from the ability to mediate rewards 3. Legitimate power: Stems from the target’s acceptance of a role relatiuaship with the agent that obligates the target to comply with the agent’s request 4. Expert power: Stems from the target’s attribution of superior knowledge or ability to the agent 5. Referent power: Stems from the target’s utilization of others as a “frame of reference” to evaiuate his orher behavior 6. Informational power: Stems from the persuasiveness of the information communicated by the agent to the target . QMH employs a total of 4%) HKS
Volume 19 Number 1
Staff compliance with infection control policies
February 1991
43
Table 1. Reports of nurses and housekeeping staff on the power base that will most likely secure compliance to infection control policies Hong Kong*
Power base Coercive Reward Legitimate Expert Referent Informational ‘Differences between a and b are significant by chi-square with Yates correctIon. tSee reference 2.
No. of staff nurses (%) (n = 142) a
No. of HKS (%) (n = 140) b
1 (O.Ol),
11 12 42 30 12 33
8 (5% 10 40 4 79
(7.0), (28.2), (2.8)8 (55.6),
(7.9), (8.6), (3Oh (21 .4)8 (8.6), (23.6),
@ < 0.001, x2 = 53 1). Groups in the same row with different subscripts
and 1400 staff nurses. With the use of a random numbers table, a random sample of 150 HKS and a stratified random sample of 150 nurses, proportional to the rank distribution in the hospital, were selected. Survey on staff compliance. The subjects were personally interviewed by the three infection control nurses (ICNs) in the hospital during November 1987. According to the sequence in Table 1, respondents were first given these definitions for the six bases of power, both orally and in writing, and then the following instruction: “A new policy that is appropriate for preventing infection is introduced by the ICN. Which power base would most likely secure your compliance with the policy?” The survey was completed within 2 weeks. RESULTS
A total of 142 nurses and 140 HKS were interviewed, whereas 18 subjects were either on leave or had resigned. Among the nurses were 25 students (18%) 12 licensed vocational nurses (8%), 95 registered nurses (67%) and 10 head nurses (7%). The majority were women (89%), and the mean duration of service in the hospital was 5 years. For the HKS 71% were women and the mean duration of service was 11 years. The responses in the survey are shown in Table 1, which includes the results of the SENIC study for comparison. 2 As shown, the highest responses reported by the nurses in both studies were for expert and informational power. How-
% of U.S. staff nurses (SENIC)t (n = 7069) 0.3 0.1 2.1 56.1 4.4 36.9 differ significantly
@ < 0.05)
ever, unlike the SENIC result, the response reported for informational power in: this study (56%) was higher than that of expert power (28%).
In this study the responses reported by the HKS differed significantly (p < 0.001, x2 = 53) from that of the nurses. For the nurses the response reported for informational power (56%) was the highest and this was significantly higher (p < 0.001, x2 = 28.9) than the 24% for the HKS. On the other hand, the highest response reported by the HKS was for legitimate power (30%) and this was significantly higher (p < 0.001, x2 = 23.2) than the 7% for the nurses. In both groups the response to expert power was fairly high (28% for nurses, 21% for HKS) and no significant difference was noted between them (p = 0.24, x2 = 1.37). The response to coercive power was the lowest for both groups, and the response reported by the HKS (8%) was significantly higher (p < 0.01, x2 = 7.1) than the nurses (0.01%). DISCUSSION
Social power and influence occupy a central place in organizational and social psychology research4 but is a neglected area in infection control.’ A recent review4 identified 18 separate studies in the literature that used the French and Raven bases of power for research, and none was related to infection control. The SENIC report* is the only study that applied
Amertcan Journal of
44
Set0 et al.
INFECTION CONTROL
the bases of power to the field of infection control. Strict comparison between the results of SENIC and this study is not possible, because there is no evidence that the two samples of nurses are comparable. Nevertheless, both studies do show that for nurses the best responses are for informational and expert power. Therefore ICNs should exercise these powers when they are trying to influence their colleagues with regard to infection control. As suggested by Haley et al., 5 this should include the provision of “relevant references and convincing information,” including local surveillance data. The response to expert power reported by nurses in this study was less than that in SENIC. This could be related to the short history of infection control in Hong Kong; ICNs were deployed at QMH only in July 1985 and consequently their status as infection control experts was not as established as in the United States. A significant finding in this study is the differences in response between HKS and nurses. This is not altogether unexpected, because the two groups are different in many aspects, including educational background, age, and sex ratio. However, it would be important for ICNs in Hong Kong to realize that HKS are more responsive to legitimate and coercive power and less to informational power. Therefore, to
influence the HKS, it would be advantageous to present the request as coming from a legitimate superior; in addition, evidence of their supervisor’s endorsement should always be shown. Besides social influence, the findings in this study should also be highly relevant for hospital staff education. In the education of nurses, the quality and type of information is probably crucial and the teacher should be proficient enough to come across as an expert. On the other hand, for the HKS the teacher can probably be more dogmatic. It would be crucial for the teacher to show that the education program has been fully approved by the hospital administration. Refwenoes 1. Raven BH, Haley RW. Social science perspective in hospital infection control. In: Johnson AW, Grusky 0, Raven BH, eds. Contemporary health services: a social science perspective. Boston: Auburn House, 198 1: i39-75. 2. Raven BH, Haley RW. Social influence and compliance of hospital nurses with infection control policies. In: Eiser RJ, ed. Social psychology and behavioral medicine. New York: John Wiley, 1982:413-38. 3. French JRP, Raven BH. The bases of social power. In: Cartwright D, ed. Studies in social power. Ann Arbor: University of Michigan, 1959:150-67. 4. Podsakoff PM, Schriesheim CA. Field studies of French and Raven’s bases of power: critique, reanalysis, and suggestions for future research. PsycholBull 1985;97: 387-411. 5. Haley RW, Aber RC, Bennett JV. Surveillance of nosocomial infection. In: Bennett JV, Brachman PS, eds. Ho+ pita1 infections. 2nd ed. Boston: Little Brown & Co, 1986:51-71.
r-
Bound volumes available to subscribers Bound volumes of AMERICANJOURNALOFINFECTIONCONTROLare available to subscribers (only) for the 1991 issues from the Publisher, at a cost of $19.00 ($25.00 international) for Vol. 19 (January-December). Shipping charges are included. Each bound volume contains a subject and an author index. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, Missouri 63146-3318, USA; phone 800-325-4177, ext. 4351.
Subs&ptions must be in force to qualify, Bound volumes are not avatlobk of a regular journal subscription.
in plplw
