CPD
CONTINUING PROFESSIONAL DEVELOPMENT
Understanding non-compliance with hand hygiene practices NS791 Gluyas H (2015) Understanding non-compliance with hand hygiene practices. Nursing Standard. 29, 35, 40-46. Date of submission: January 20 2015; date of acceptance: February 5 2015.
Aims and intended learning outcomes
Abstract Healthcare-associated infections (HCAIs) continue to be a challenge in developed and developing countries. Hand hygiene practice is considered to be the most effective strategy to prevent HCAIs, but healthcare workers’ compliance is poor. Using a human factors perspective, this article explores elements that affect healthcare workers’ hand hygiene compliance. Slips, lapses and mistakes can occur depending on the worker’s skills and knowledge levels. Violations of protocols may also occur, and these may be associated with the intention to provide care efficiently. Strong leadership and an understanding of why non-compliance with hand hygiene occurs assists with developing strategies to improve compliance.
Author Heather Gluyas Associate professor, School of Health Professions, Murdoch University, Mandurah, Western Australia, Australia. Correspondence to: [email protected]
This article aims to inform nurses and other healthcare professionals, using a human factors perspective, about factors that lead to policy and protocol violations associated with poor compliance with hand hygiene practices. After reading this article and completing the time out activities you should be able to: Describe the principal elements involved in hand hygiene practices in healthcare settings. Identify the cognitive processes that can lead to errors. Identify the different types of violations involved in hand hygiene errors. Apply knowledge of hand hygiene to the work environment.
Introduction
Keywords Cognitive performance, compliance, hand hygiene, handwashing, healthcare associated infections, human factors, infection control, patient safety, violations
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Revalidation Prepare for revalidation: read this CPD article, answer the questionnaire and write a reflective account.
Online For related articles visit the archive and search using the keywords above. To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines
Healthcare-associated infections (HCAIs) continue to be a challenge, and the costs to healthcare systems and patients in financial and human terms creates a burden (World Health Organization (WHO) 2011). Compliance with hand hygiene practices is considered to be the most effective strategy to prevent HCAIs (Allegranzi et al 2010, Erasmus et al 2010, Kirkland et al 2012, Azim and McLaws 2014). However, even with this knowledge, compliance with hand hygiene practices by healthcare workers remains patchy, with an overall median compliance rate of 40% (Erasmus et al 2010). Using knowledge from the discipline of human factors, the focus of this article is to understand factors that lead to hand hygiene policy and protocol violations by healthcare workers.
Background In the 1840s, Ignaz Semmelweis demonstrated that when medical students and staff washed their hands before attending to women giving birth, the rate of mortality from infections
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was reduced from 13-18% to 2% (Best and Neuhauser 2004). Florence Nightingale also recognised the importance of hand washing in the prevention of infection in the mid-1800s (Nightingale 1859, Lim 2010). These clinicians experienced derision, disbelief and resistance to the implementation of hand hygiene regimens. However, science has validated their claims by demonstrating the presence of pathogens and the crucial role of handwashing in preventing the spread of the micro-organisms that lead to HCAIs (Allegranzi et al 2011). Complete time out activity 1
Rotational rubbing of left thumb clasped in right palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. Performing hand-rub for 20-30 seconds and handwashing for 40-60 seconds. When using hand rub, hand hygiene is complete once hands are dry. When handwashing, hand hygiene is complete after hands are rinsed, dried with a paper towel, and the towel is used to turn off the tap. Complete time out activity 2
The SAVE LIVES: Clean Your Hands campaign (WHO 2009a) galvanised commitment from many countries to improve hand hygiene practices in healthcare settings. As part of the campaign, WHO developed hand hygiene improvement strategies targeting organisational systems and the behaviour of healthcare workers. These strategies have included: the introduction of hand hygiene products; an increase in the number, and strategic placement, of sinks, soap and hand rub dispensers; education programmes; reminders and prompts such as posters; and a focus on organisational safety (WHO 2009b). While this has had an effect on increasing compliance with hand hygiene practices and a decrease in HCAIs in some organisations, overall compliance rates remain low (Erasmus et al 2010, Filion et al 2011, Stewardson and Pittet 2012, WHO 2013). The SAVE LIVES campaign identified principles required for effective hand hygiene, including the five moments in clinical care for hand hygiene (Box 1), and the most effective technique for cleansing using both hand rub and soap and water. Hand-rub and handwashing techniques are the same except for the duration of the procedure, the initial application of the product, and the requirement to dry hands if handwashing rather than air-drying them when hand rub is used. The techniques involve (WHO 2009c): Applying product to cupped hand for hand rub or wetting hands with water and applying soap to cover all hand surfaces for handwashing. Rubbing hands palm to palm. Rubbing right hand over left dorsum with interlaced fingers and vice versa. Rubbing palm to palm with interlaced fingers. Rubbing backs of fingers to opposing palms with fingers interlocked.
Many studies have investigated the reasons for poor compliance with hand hygiene practices (Erasmus et al 2010). Factors implicated include lack of time, workload pressures, lack of knowledge, poor role modelling by other healthcare professionals and a lack of organisational support (Gluyas and Morrison 2013). These factors are common in the organisational systems and working environment in which healthcare workers cognitively process and make decisions about actions and tasks. The discipline of human factors promotes understanding of the effect of these factors on the cognitive processes and decision making by healthcare workers at the point of care.
Human factors and cognitive performance The relationship and interaction between how people think (cognitive processes) and act, the environment they are working in, and the tools they are using are studied in the discipline of human factors (Gluyas and Morrison 2013). The knowledge can provide an understanding of errors and deliberate violations of accepted practice and also identify strategies that will reduce these issues. Cognitive processes allow humans to solve problems, undertake several tasks at the same
Join our First Friday Twitter discussion on issues raised in this article. Friday May 1 from 12.30-1.30 using #NurseJC
1 List the reasons you think might contribute to low hand hygiene compliance rates. Ask your colleagues what reasons they think contribute to non-compliance with hand hygiene requirements. 2 Review the essential elements for hand cleansing and access the diagrams at tinyurl. com/8xykftt. Using this information, review your technique for hand hygiene. Identify changes that you need to make to improve your hand hygiene practice.
BOX 1 The five moments in clinical care requiring hand hygiene Before touching a patient, such as helping them to move or holding their hand. Before a clean or aseptic procedure, such as performing wound dressings or personal hygiene tasks. After risk of exposure to body fluid, such as when changing a urinary catheter or obtaining blood samples. After touching a patient, such as helping them to move or holding their hand. After touching patient surroundings, such as linen, patient monitoring equipment or tray table. (World Health Organization 2009a, 2009b)
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CPD infection control time and apply information from one situation to a different situation to complete tasks. This is done by undertaking tasks with a combination of automatic and conscious thoughts and actions. However, these cognitive skills have shortcomings; humans have limited cognitive processing ability, resulting in prioritisation of where our attention is focused (Frankel and Leonard 2003). Depending on our familiarity with and knowledge of the task requirements, we use either skill, rule or knowledge-based cognitive performance (Carayon 2012). The attributes of these different types of cognitive performance are summarised in Box 2. The different levels of performance are associated with different types of error: slips and lapses are associated with skill-based performance, and mistakes with rule and knowledge-based performance (Carayon 2012). Complete time out activity 3 Slips and lapses (skill-based errors) occur when we forget to do something or we miss a step in a procedure. They are more likely to happen when we are undertaking tasks with which we are familiar and that require little conscious thought. Mistakes occur when we are consciously paying attention to the task, and are more likely to be related to a lack of knowledge (knowledge-based errors) or application of the wrong rule or incorrect application of the rule to undertake the task at hand (rule-based errors) (Carayon 2012). Skill, knowledge and rule-based errors are
exacerbated by tiredness, heavy workload, multiple distractions and other stress factors (Gluyas and Morrison 2013). In these types of scenarios, hand hygiene practices can be negatively affected.
Violations
Errors can also occur when humans deliberately decide not to follow procedures or work requirements. These errors, called violations, differ from slips, lapses and mistakes in that departures from procedures and protocols are deliberate choices on the part of the healthcare worker. Violations could be dismissed as aberrant or negligent behaviour on the part of the healthcare worker. However, the decision to violate the rules and protocol is associated with the intention to complete tasks in the most efficient manner. It is important to understand that, although the person chooses to deviate from the rules, the resulting error and any harm that might arise from these violations was not intended (Carayon 2012). There are different types of violations related to different triggers (Box 3).
Erroneous violations Erroneous violations
differ from other types of violation in that the person does not make an intentional decision to deviate from the rules, but rather that lack of knowledge and understanding form the basis of the decision, in most cases. Erroneous violations may be considered knowledge-based mistakes. A lack of knowledge can lead to a healthcare
BOX 2 Cognitive function related to undertaking different types of action Skill-based actions: Involve unconscious or automatic control of actions based on practice. Require limited attention. Are fast and effortless. Errors occur when we are undertaking routine familiar actions, or are preoccupied or distracted. Are associated with slips and lapses in performance of tasks.
3 Reflect on recent errors you may have made, preferably in your work area but examples from everyday life are suitable. Make a list of things that may have contributed to the errors and classify whether the errors were related to skill, rule or knowledge-based actions.
Rule-based actions: Adapt automatic behaviour to cope with changed circumstances. Develop cognitive rules to manage this from experience or training. Errors occur when we apply a rule where there are contraindications, apply the wrong rule, or do not apply a good rule. Are associated with mistakes in performance of tasks. Knowledge-based actions: Are managed by the application of conscious attention. Are used for new or novel situations. Require high effort and are comparatively slow. Errors occur when we do not have the knowledge to undertake the actions. Are associated with mistakes in performance of tasks. (Reason 2008, Carayon 2012)
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worker not identifying instances where hand hygiene is required. In a study undertaken by McLaughlin et al (2013), healthcare workers undertook a knowledge questionnaire of hand hygiene practices in which the average score was 26.55 out of 35 questions answered correctly and some items were answered correctly less than 60% of the time. This study was undertaken in Australia, where hand hygiene practices and compliance rate reporting are mandated at a national level. The rates reported in this study were surprising given the focus on hand hygiene in recent years and belie the assumption that healthcare workers are familiar with and understand when hand hygiene should take place in the clinical setting, as well as knowing the most effective way to cleanse hands. Education programmes targeting the ‘when, how and why’ of effective hand hygiene must therefore continue, with all healthcare workers having access to this information.
Exceptional violations Exceptional violations are those that occur as a response to unusual situations. In some circumstances, complying with hand hygiene requirements may be difficult, such as situations where a response to a patient’s condition is required immediately; for example, when preventing a child from falling, assisting a patient who is choking or helping a person who is collapsing; situations where the initial problem has to be managed as an immediate priority. Complying with the time requirement to perform handwashing (40-60 seconds) or hand-rub (20-30 seconds) is unrealistic in these situations. However, what
can happen at these times is the healthcare worker getting caught up in the response and not taking the opportunity to perform hand hygiene when it becomes available. This is less likely to occur if the healthcare worker perceives a risk of infection to themselves, such as contact with body fluids, because this is a motivator to perform hand hygiene (McLaughlin et al 2013).
Situational violations Decisions about task actions are influenced by the context, which in health care is often time-pressured, with competing and continually changing priorities and goals. In this environment, the healthcare worker is constantly assessing what must be done versus what should be done. When making decisions about actions, people evaluate the risks involved in undertaking or not undertaking an action. However, we tend to evaluate the likelihood of poor outcomes occurring, rather than the consequences of a poor outcome (McLaughlin et al 2013). Everyday life is filled with decisions that lead to situational violations. Examples are choosing to cross the road against the traffic signal or choosing to exceed traffic speed limits. Often these do not result in negative outcomes, such as being hit by a car when crossing the road or having an accident when speeding. So the choice not to follow the rules is based on expectation of the low likelihood of negative outcomes occurring, rather than an evaluation of the severity of the consequences if a negative outcome were to occur. When applying this to hand hygiene, the decision not to follow protocols is based on a
BOX 3 Types of violations and hand hygiene examples Erroneous violations (lack of understanding): Lack of knowledge of healthcare-associated infection risk related to poor hand hygiene. Exceptional violations (unusual circumstances require unusual responses): Emergency situations where time is of the essence and hand hygiene practices are ignored or completed below minimum requirements. Situational violations (related to constraints of environment): Lack of washbasins or hand hygiene products in patient care areas make it difficult to comply with hand hygiene practices. Workload and poor staffing levels result in perceived lack of time for healthcare workers to comply with effective hand hygiene. Assessment of risk is related to likelihood rather than consequence. Routine violations (shortcuts or workarounds that happen on a regular basis): Cultural climate that accepts poor practice of hand hygiene requirements. Poor role modelling by senior staff makes it difficult for junior staff to challenge unacceptable practice and/or maintain accepted standards of hand hygiene practices. Lack of organisational leadership commitment. (Lawton 1998, Catchpole 2013)
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CPD infection control perception of low risk of a negative outcome; that is, the likelihood of a patient developing an HCAI from the violation is perceived to be low. This choice is further complicated because, if the patient does develop an HCAI, this will occur long after the violation of not following hand hygiene protocols. An infection develops in days rather than minutes or hours, and so the relationship between the violation and the likelihood of a negative consequence is lost (Carayon 2012). Thus, in situations where washbasins or hand gel are not conveniently located to the workflow processes, or the healthcare worker is trying to balance competing tasks in a short time frame, the decision to bypass hand hygiene protocols may seem low risk and therefore reasonable to the healthcare worker (Lawton 1998, Alper and Karsh 2009, McLaughlin et al 2013). This perception of low risk also contributes to lower hand hygiene compliance rates when healthcare workers believe some of the five moments in clinical care (Box 1) are more risky than others (Erasmus et al 2010). Several studies have reported healthcare workers perceiving non-compliance with hand hygiene requirements before touching patients and after touching patient surfaces to be less risky than such omission after physical contact with a patient (Erasmus et al 2010, McLaughlin and Walsh 2011). This is a flawed perception since the most common HCAIs result from bacteria that survive on surfaces for many months (McLaughlin et al 2013). Nevertheless, compliance rates have been noted to be less for these hand hygiene moments, and are usually higher for moments that involve patient contact (Erasmus et al 2010, Hand Hygiene Australia 2014). The misconception that touching patient surfaces is less risky provides false reassurance for healthcare workers that they are undertaking hand hygiene when it matters most, and are therefore doing so efficiently.
Routine violations Violations that do not
4 Review your compliance with hand hygiene requirements. Classify your non-compliant practice in relation to the different types of violations.
result in adverse outcomes tend to reinforce the perception of low risk among healthcare workers (Alper and Karsh 2009). Exceptional and situational violations are discrete actions in themselves, providing a choice for the healthcare worker based on circumstances they are experiencing at the time. However, if these violations effectively meet other needs in providing a strategy to manage competing work demands, with no apparent negative consequences, they can become routine accepted
practice. A perception that senior clinical staff and the management team are aware of the violation practices and are choosing to ignore them effectively reinforces the ongoing poor practice (Azim and McLaws 2014). Complete time out activity 4
Human factors strategies to improve hand hygiene There have been many strategies and interventions employed to improve hand hygiene practices. Sustained improvement has been patchy but, where there has been greater success, a combination of factors has been involved. System strategies that attempt to address the knowledge, environmental and work pressures that might lead to poor hand hygiene practices have been reported (Allegranzi et al 2010, Kirkland et al 2012, Stewardson and Pittet 2012). Knowledge of the cognitive processes that can lead to errors and deliberate violations provides the opportunity to identify strategies that deliberately target such processes to lessen the likelihood of errors. All strategies to improve hand hygiene require leadership, commitment and resourcing. This commitment must elevate hand hygiene as an organisational priority and ensure active role modelling of the requirements for effective hand hygiene are foremost in healthcare workers’ clinical practice (Stewardson and Pittet 2012).
Strategies targeting slips, lapses and mistakes
Strategies that focus on improving an individual healthcare worker’s understanding of the cognitive processes that lead to slips, lapses and mistakes provide insight into situational pressures and where errors are more likely to occur. One such strategy is Foresight Training, which encourages NHS staff to evaluate pressures during their daily work situations, in the realms of self, context and task, that may increase the likelihood of slips, lapses or mistakes occurring (Norris 2012). Staff are able to use this information to identify that they are at increased risk of making errors (Reason 2000, Boakes 2009). While this strategy is not specifically targeted at hand hygiene practices, it can highlight increased likelihood of errors in all domains of care. Having noted that lapses can be a major contributor to non-compliance as busy healthcare workers focus on their workload
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and forget to perform hand hygiene, Chassin et al (2015) suggest training coaches and peers to remind healthcare workers to wash their hands when appropriate. This could take the form of using a code word to alert peers to their lapse or some other form of discreet communication to remind others of the missed opportunity to perform hand hygiene. These coaches could also be used to reinforce education programmes on the rationale for effective hand hygiene. This may be more meaningful for some healthcare workers because the theoretical knowledge will be reinforced in relation to specific clinical settings and roles. Further opportunities to remind healthcare workers of the requirement for hand hygiene at the point of care could be provided during audits of hand hygiene rates. Currently, most reporting of hand hygiene compliance rates relies on observation of the number of actual performances of hand hygiene compared with the total number of times it should have been performed; the auditors avoid interactions with the healthcare workers being observed. There are potential problems with the veracity of observational audits because direct observation may result in rates being overstated; although there is no interaction between the healthcare workers and the auditor, healthcare workers are often aware of the presence of the auditor and this may lead to what is known as the Hawthorne effect, where an individual’s behaviour changes because they become aware of observation (Erasmus et al 2010). Srigley et al (2014) found support for this assertion in a study comparing hand hygiene observation rates with rates captured via electronic monitoring in the same clinical setting – the rate for the former was three times higher. However, Azim and McLaws (2014) propose that, rather than focusing on this discrepancy in reporting rates, the phenomenon of being reminded by the presence of the auditor to perform hand hygiene could be used as a formal improvement strategy. Therefore, the process of auditing could involve the auditor reminding the healthcare worker to perform hand hygiene when required, rather than recording non-compliance. The audits could record the number of times healthcare workers need to be reminded, rather than recording non-compliance. Visual cues such as posters and stickers also have a role in reminding healthcare workers of hand hygiene opportunities and techniques.
These, however, cease to be effective if they are not changed frequently because people become used to seeing them and cease to notice them over time (Filion et al 2011).
Strategies targeting violations
Appreciating that violations related to situational factors often occur because of a lack of available equipment at the point of care puts focus on the placement of washbasins and hand gel stations. These should be appropriately located in relation to the usual patterns of workflow, both in patients’ rooms and in corridors and work rooms. There should also be dedicated spaces where healthcare workers can place objects they may be carrying so they are able to perform hand hygiene (Chassin et al 2015). Complete time out activity 5 In hand hygiene violations where non-compliance has become routine and accepted practice, peer pressure and role modelling are determinants of hand hygiene compliance. In a study examining the role of doctors in determining the hand hygiene practices of the rest of the team, researchers found that, if the doctor performed hand hygiene, the compliance rate of the team was 66%, compared with 42% if this did not occur (Haessler et al 2012). The researchers also identified that it was not just doctors who could influence behaviour; regardless of role, if the first person in the team performed hand hygiene then it was more likely that others would do so (Haessler et al 2012). Complete time out activity 6 Involving patients and families in hand hygiene programmes provides an opportunity for the healthcare worker to be cued to the requirement for hand hygiene. While this sounds like a simple solution, there are many barriers to be overcome for patients to feel safe in challenging healthcare workers and for healthcare workers to respond appropriately to patients asking them to perform hand hygiene. Nevertheless, where patients were educated on admission to ask healthcare workers to wash their hands, hand hygiene showed significant improvement (Longtin et al 2010).
Conclusion Improving healthcare workers’ compliance with hand hygiene protocols is imperative if we are to reduce HCAI rates. Understanding the cognitive
5 Informally audit your workplace for the location of washbasins and hand gel stations. Are they where you are most likely to use them in relation to your workflow? Are there reminders visible by the washbasins and hand gel stations that demonstrate the correct technique for hand hygiene? Is there a place to put objects you may be carrying while you are performing hand hygiene? 6 Imagine you are about to replace a patient’s dressing and the patient asks if you have washed your hands. How do you think you would react? How do you think you would react if a colleague reminded you to perform hand hygiene before starting the dressing?
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CPD infection control
7 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 50.
processes involved in undertaking tasks identifies those circumstances when healthcare workers may forget to wash their hands or perceive that hand hygiene is not necessary. It is important to recognise that, in situations where healthcare workers perceive low risk, deliberate hand hygiene violations can occur. In some areas, these violations can become
routine practice. Improvement in compliance with hand hygiene practices requires targeted interventions that address organisational constraints, training and education, and organisational safety culture, and also challenge healthcare workers’ perceptions of low risk that lead to hand hygiene protocol violations NS Complete time out activity 7
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eight hospitals in the United States by targeting specific causes of noncompliance. Joint Commission Journal on Quality and Patient Safety. 41, 1, 4-12. Erasmus V, Daha T, Brug H et al (2010) Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control and Hospital Epidemiology. 31, 3, 283-294. Filion K, Kukanich K, Chapman B, Hardigree M, Powell D (2011) Observation-based evaluation of hand hygiene practices and the effects of an intervention at a public hospital cafeteria. American Journal of Infection Control. 39, 6, 464-470. Frankel A, Leonard M (2003) Why is Communication and Teamwork so Critical to the Healthcare Industry? Presentation. http://patientsafety. im.wustl.edu/content/documents/ WhyCommunicationisCritical.pdf (Last accessed: April 9 2015.) Gluyas H, Morrison P (2013) Patient Safety: An Essential Guide. Palgrave Macmillan, London. Haessler S, Bhagavan A, Kleppel R, Hinchey K, Visintainer P (2012) Getting doctors to clean their hands: lead the followers. BMJ Quality and Safety. 21, 6, 499-502. Hand Hygiene Australia (2014) National Data Period Three, 2014. www.hha.org.au/ LatestNationalData.aspx (Last accessed: April 9 2015.) Kirkland K, Homa K, Lasky R, Ptak J, Taylor E, Splaine M (2012) Impact of a hospital-wide hand hygiene initiative on healthcare-associated
infections: results of an interrupted time series. BMJ Quality and Safety. 21, 12, 1019-1026. Lawton R (1998) Not working to rule: understanding procedural violations at work. Safety Science. 28, 2, 77-95. Lim F (2010) Why Florence Nightingale still matters. Nursing. 40, 11, 46-47. Longtin Y, Sax H, Leape L, Sheridan S, Donaldson L, Pittet D (2010) Patient participation: current knowledge and applicability to patient safety. Mayo Clinic Proceedings. 85, 1, 53-62. McLaughlin A, Walsh F (2011) Individual differences in judgments of hand hygiene risk by health care workers. American Journal of Infection Control. 39, 6, 356-463. McLaughlin A, Walsh F, Bryant M (2013) Effects of knowledge and internal locus of control in groups of health care workers judging likelihood of pathogen transfer. Human Factors. 55, 4, 803-814. Nightingale F (1859) Notes on Nursing: What it is and What it is Not. Lippincott, Philadelphia PA. Norris B (2012) The diversity of human factors: illustrating the relevance for nursing. Nursing Standard. 26, 33, 35-40. Reason J (2000) Human error: models and management. British Medical Journal. 320, 7237, 768-770. Reason J (2008) The Human Contribution: Unsafe Acts, Accidents
and Heroic Recoveries. Ashgate Publishing Limited, Farnham. Srigley J, Furness C, Ross Baker G, Gardam M (2014) Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Quality and Safety. 23, 12, 974-980. Stewardson A, Pittet D (2012) Anatomy of a successful multimodal hand hygiene campaign. BMJ Quality and Safety. 21, 12, 973-975. World Health Organization (2009a) SAVE LIVES: Clean Your Hands. WHO Guide to Implementation. tinyurl.com/lo43e8g (Last accessed: April 9 2015.) World Health Organization (2009b) WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge. Clean Care is Safer Care. tinyurl. com/ybwu8b5 (Last accessed: April 9 2015.) World Health Organization (2009c) Hand Hygiene: Why, How & When? tinyurl.com/png82aq (Last accessed: April 9 2015.) World Health Organization (2011) Report on the Burden of Endemic Health Care-Associated Infection Worldwide. tinyurl.com/7vhx6g7 (Last accessed: April 9 2015.) World Health Organization (2013) Evidence of Hand Hygiene to Reduce Transmission and Infections by Multi-Drug Resistant Organisms in Health-Care Settings. tinyurl. com/kt7hBwq (Last accessed: April 9 2015.)
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CONTINUING PROFESSIONAL DEVELOPMENT
Understanding non-compliance with hand hygiene practices NS791 Gluyas H (2015) Understanding non-compliance with hand hygiene practices. Nursing Standard. 29, 35, 40-46. Date of submission: January 20 2015; date of acceptance: February 5 2015.
Aims and intended learning outcomes
Abstract Healthcare-associated infections (HCAIs) continue to be a challenge in developed and developing countries. Hand hygiene practice is considered to be the most effective strategy to prevent HCAIs, but healthcare workers’ compliance is poor. Using a human factors perspective, this article explores elements that affect healthcare workers’ hand hygiene compliance. Slips, lapses and mistakes can occur depending on the worker’s skills and knowledge levels. Violations of protocols may also occur, and these may be associated with the intention to provide care efficiently. Strong leadership and an understanding of why non-compliance with hand hygiene occurs assists with developing strategies to improve compliance.
Author Heather Gluyas Associate professor, School of Health Professions, Murdoch University, Mandurah, Western Australia, Australia. Correspondence to: [email protected]
This article aims to inform nurses and other healthcare professionals, using a human factors perspective, about factors that lead to policy and protocol violations associated with poor compliance with hand hygiene practices. After reading this article and completing the time out activities you should be able to: Describe the principal elements involved in hand hygiene practices in healthcare settings. Identify the cognitive processes that can lead to errors. Identify the different types of violations involved in hand hygiene errors. Apply knowledge of hand hygiene to the work environment.
Introduction
Keywords Cognitive performance, compliance, hand hygiene, handwashing, healthcare associated infections, human factors, infection control, patient safety, violations
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Revalidation Prepare for revalidation: read this CPD article, answer the questionnaire and write a reflective account.
Online For related articles visit the archive and search using the keywords above. To write a CPD article: please email [email protected] Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines
Healthcare-associated infections (HCAIs) continue to be a challenge, and the costs to healthcare systems and patients in financial and human terms creates a burden (World Health Organization (WHO) 2011). Compliance with hand hygiene practices is considered to be the most effective strategy to prevent HCAIs (Allegranzi et al 2010, Erasmus et al 2010, Kirkland et al 2012, Azim and McLaws 2014). However, even with this knowledge, compliance with hand hygiene practices by healthcare workers remains patchy, with an overall median compliance rate of 40% (Erasmus et al 2010). Using knowledge from the discipline of human factors, the focus of this article is to understand factors that lead to hand hygiene policy and protocol violations by healthcare workers.
Background In the 1840s, Ignaz Semmelweis demonstrated that when medical students and staff washed their hands before attending to women giving birth, the rate of mortality from infections
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was reduced from 13-18% to 2% (Best and Neuhauser 2004). Florence Nightingale also recognised the importance of hand washing in the prevention of infection in the mid-1800s (Nightingale 1859, Lim 2010). These clinicians experienced derision, disbelief and resistance to the implementation of hand hygiene regimens. However, science has validated their claims by demonstrating the presence of pathogens and the crucial role of handwashing in preventing the spread of the micro-organisms that lead to HCAIs (Allegranzi et al 2011). Complete time out activity 1
Rotational rubbing of left thumb clasped in right palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa. Performing hand-rub for 20-30 seconds and handwashing for 40-60 seconds. When using hand rub, hand hygiene is complete once hands are dry. When handwashing, hand hygiene is complete after hands are rinsed, dried with a paper towel, and the towel is used to turn off the tap. Complete time out activity 2
The SAVE LIVES: Clean Your Hands campaign (WHO 2009a) galvanised commitment from many countries to improve hand hygiene practices in healthcare settings. As part of the campaign, WHO developed hand hygiene improvement strategies targeting organisational systems and the behaviour of healthcare workers. These strategies have included: the introduction of hand hygiene products; an increase in the number, and strategic placement, of sinks, soap and hand rub dispensers; education programmes; reminders and prompts such as posters; and a focus on organisational safety (WHO 2009b). While this has had an effect on increasing compliance with hand hygiene practices and a decrease in HCAIs in some organisations, overall compliance rates remain low (Erasmus et al 2010, Filion et al 2011, Stewardson and Pittet 2012, WHO 2013). The SAVE LIVES campaign identified principles required for effective hand hygiene, including the five moments in clinical care for hand hygiene (Box 1), and the most effective technique for cleansing using both hand rub and soap and water. Hand-rub and handwashing techniques are the same except for the duration of the procedure, the initial application of the product, and the requirement to dry hands if handwashing rather than air-drying them when hand rub is used. The techniques involve (WHO 2009c): Applying product to cupped hand for hand rub or wetting hands with water and applying soap to cover all hand surfaces for handwashing. Rubbing hands palm to palm. Rubbing right hand over left dorsum with interlaced fingers and vice versa. Rubbing palm to palm with interlaced fingers. Rubbing backs of fingers to opposing palms with fingers interlocked.
Many studies have investigated the reasons for poor compliance with hand hygiene practices (Erasmus et al 2010). Factors implicated include lack of time, workload pressures, lack of knowledge, poor role modelling by other healthcare professionals and a lack of organisational support (Gluyas and Morrison 2013). These factors are common in the organisational systems and working environment in which healthcare workers cognitively process and make decisions about actions and tasks. The discipline of human factors promotes understanding of the effect of these factors on the cognitive processes and decision making by healthcare workers at the point of care.
Human factors and cognitive performance The relationship and interaction between how people think (cognitive processes) and act, the environment they are working in, and the tools they are using are studied in the discipline of human factors (Gluyas and Morrison 2013). The knowledge can provide an understanding of errors and deliberate violations of accepted practice and also identify strategies that will reduce these issues. Cognitive processes allow humans to solve problems, undertake several tasks at the same
Join our First Friday Twitter discussion on issues raised in this article. Friday May 1 from 12.30-1.30 using #NurseJC
1 List the reasons you think might contribute to low hand hygiene compliance rates. Ask your colleagues what reasons they think contribute to non-compliance with hand hygiene requirements. 2 Review the essential elements for hand cleansing and access the diagrams at tinyurl. com/8xykftt. Using this information, review your technique for hand hygiene. Identify changes that you need to make to improve your hand hygiene practice.
BOX 1 The five moments in clinical care requiring hand hygiene Before touching a patient, such as helping them to move or holding their hand. Before a clean or aseptic procedure, such as performing wound dressings or personal hygiene tasks. After risk of exposure to body fluid, such as when changing a urinary catheter or obtaining blood samples. After touching a patient, such as helping them to move or holding their hand. After touching patient surroundings, such as linen, patient monitoring equipment or tray table. (World Health Organization 2009a, 2009b)
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CPD infection control time and apply information from one situation to a different situation to complete tasks. This is done by undertaking tasks with a combination of automatic and conscious thoughts and actions. However, these cognitive skills have shortcomings; humans have limited cognitive processing ability, resulting in prioritisation of where our attention is focused (Frankel and Leonard 2003). Depending on our familiarity with and knowledge of the task requirements, we use either skill, rule or knowledge-based cognitive performance (Carayon 2012). The attributes of these different types of cognitive performance are summarised in Box 2. The different levels of performance are associated with different types of error: slips and lapses are associated with skill-based performance, and mistakes with rule and knowledge-based performance (Carayon 2012). Complete time out activity 3 Slips and lapses (skill-based errors) occur when we forget to do something or we miss a step in a procedure. They are more likely to happen when we are undertaking tasks with which we are familiar and that require little conscious thought. Mistakes occur when we are consciously paying attention to the task, and are more likely to be related to a lack of knowledge (knowledge-based errors) or application of the wrong rule or incorrect application of the rule to undertake the task at hand (rule-based errors) (Carayon 2012). Skill, knowledge and rule-based errors are
exacerbated by tiredness, heavy workload, multiple distractions and other stress factors (Gluyas and Morrison 2013). In these types of scenarios, hand hygiene practices can be negatively affected.
Violations
Errors can also occur when humans deliberately decide not to follow procedures or work requirements. These errors, called violations, differ from slips, lapses and mistakes in that departures from procedures and protocols are deliberate choices on the part of the healthcare worker. Violations could be dismissed as aberrant or negligent behaviour on the part of the healthcare worker. However, the decision to violate the rules and protocol is associated with the intention to complete tasks in the most efficient manner. It is important to understand that, although the person chooses to deviate from the rules, the resulting error and any harm that might arise from these violations was not intended (Carayon 2012). There are different types of violations related to different triggers (Box 3).
Erroneous violations Erroneous violations
differ from other types of violation in that the person does not make an intentional decision to deviate from the rules, but rather that lack of knowledge and understanding form the basis of the decision, in most cases. Erroneous violations may be considered knowledge-based mistakes. A lack of knowledge can lead to a healthcare
BOX 2 Cognitive function related to undertaking different types of action Skill-based actions: Involve unconscious or automatic control of actions based on practice. Require limited attention. Are fast and effortless. Errors occur when we are undertaking routine familiar actions, or are preoccupied or distracted. Are associated with slips and lapses in performance of tasks.
3 Reflect on recent errors you may have made, preferably in your work area but examples from everyday life are suitable. Make a list of things that may have contributed to the errors and classify whether the errors were related to skill, rule or knowledge-based actions.
Rule-based actions: Adapt automatic behaviour to cope with changed circumstances. Develop cognitive rules to manage this from experience or training. Errors occur when we apply a rule where there are contraindications, apply the wrong rule, or do not apply a good rule. Are associated with mistakes in performance of tasks. Knowledge-based actions: Are managed by the application of conscious attention. Are used for new or novel situations. Require high effort and are comparatively slow. Errors occur when we do not have the knowledge to undertake the actions. Are associated with mistakes in performance of tasks. (Reason 2008, Carayon 2012)
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worker not identifying instances where hand hygiene is required. In a study undertaken by McLaughlin et al (2013), healthcare workers undertook a knowledge questionnaire of hand hygiene practices in which the average score was 26.55 out of 35 questions answered correctly and some items were answered correctly less than 60% of the time. This study was undertaken in Australia, where hand hygiene practices and compliance rate reporting are mandated at a national level. The rates reported in this study were surprising given the focus on hand hygiene in recent years and belie the assumption that healthcare workers are familiar with and understand when hand hygiene should take place in the clinical setting, as well as knowing the most effective way to cleanse hands. Education programmes targeting the ‘when, how and why’ of effective hand hygiene must therefore continue, with all healthcare workers having access to this information.
Exceptional violations Exceptional violations are those that occur as a response to unusual situations. In some circumstances, complying with hand hygiene requirements may be difficult, such as situations where a response to a patient’s condition is required immediately; for example, when preventing a child from falling, assisting a patient who is choking or helping a person who is collapsing; situations where the initial problem has to be managed as an immediate priority. Complying with the time requirement to perform handwashing (40-60 seconds) or hand-rub (20-30 seconds) is unrealistic in these situations. However, what
can happen at these times is the healthcare worker getting caught up in the response and not taking the opportunity to perform hand hygiene when it becomes available. This is less likely to occur if the healthcare worker perceives a risk of infection to themselves, such as contact with body fluids, because this is a motivator to perform hand hygiene (McLaughlin et al 2013).
Situational violations Decisions about task actions are influenced by the context, which in health care is often time-pressured, with competing and continually changing priorities and goals. In this environment, the healthcare worker is constantly assessing what must be done versus what should be done. When making decisions about actions, people evaluate the risks involved in undertaking or not undertaking an action. However, we tend to evaluate the likelihood of poor outcomes occurring, rather than the consequences of a poor outcome (McLaughlin et al 2013). Everyday life is filled with decisions that lead to situational violations. Examples are choosing to cross the road against the traffic signal or choosing to exceed traffic speed limits. Often these do not result in negative outcomes, such as being hit by a car when crossing the road or having an accident when speeding. So the choice not to follow the rules is based on expectation of the low likelihood of negative outcomes occurring, rather than an evaluation of the severity of the consequences if a negative outcome were to occur. When applying this to hand hygiene, the decision not to follow protocols is based on a
BOX 3 Types of violations and hand hygiene examples Erroneous violations (lack of understanding): Lack of knowledge of healthcare-associated infection risk related to poor hand hygiene. Exceptional violations (unusual circumstances require unusual responses): Emergency situations where time is of the essence and hand hygiene practices are ignored or completed below minimum requirements. Situational violations (related to constraints of environment): Lack of washbasins or hand hygiene products in patient care areas make it difficult to comply with hand hygiene practices. Workload and poor staffing levels result in perceived lack of time for healthcare workers to comply with effective hand hygiene. Assessment of risk is related to likelihood rather than consequence. Routine violations (shortcuts or workarounds that happen on a regular basis): Cultural climate that accepts poor practice of hand hygiene requirements. Poor role modelling by senior staff makes it difficult for junior staff to challenge unacceptable practice and/or maintain accepted standards of hand hygiene practices. Lack of organisational leadership commitment. (Lawton 1998, Catchpole 2013)
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CPD infection control perception of low risk of a negative outcome; that is, the likelihood of a patient developing an HCAI from the violation is perceived to be low. This choice is further complicated because, if the patient does develop an HCAI, this will occur long after the violation of not following hand hygiene protocols. An infection develops in days rather than minutes or hours, and so the relationship between the violation and the likelihood of a negative consequence is lost (Carayon 2012). Thus, in situations where washbasins or hand gel are not conveniently located to the workflow processes, or the healthcare worker is trying to balance competing tasks in a short time frame, the decision to bypass hand hygiene protocols may seem low risk and therefore reasonable to the healthcare worker (Lawton 1998, Alper and Karsh 2009, McLaughlin et al 2013). This perception of low risk also contributes to lower hand hygiene compliance rates when healthcare workers believe some of the five moments in clinical care (Box 1) are more risky than others (Erasmus et al 2010). Several studies have reported healthcare workers perceiving non-compliance with hand hygiene requirements before touching patients and after touching patient surfaces to be less risky than such omission after physical contact with a patient (Erasmus et al 2010, McLaughlin and Walsh 2011). This is a flawed perception since the most common HCAIs result from bacteria that survive on surfaces for many months (McLaughlin et al 2013). Nevertheless, compliance rates have been noted to be less for these hand hygiene moments, and are usually higher for moments that involve patient contact (Erasmus et al 2010, Hand Hygiene Australia 2014). The misconception that touching patient surfaces is less risky provides false reassurance for healthcare workers that they are undertaking hand hygiene when it matters most, and are therefore doing so efficiently.
Routine violations Violations that do not
4 Review your compliance with hand hygiene requirements. Classify your non-compliant practice in relation to the different types of violations.
result in adverse outcomes tend to reinforce the perception of low risk among healthcare workers (Alper and Karsh 2009). Exceptional and situational violations are discrete actions in themselves, providing a choice for the healthcare worker based on circumstances they are experiencing at the time. However, if these violations effectively meet other needs in providing a strategy to manage competing work demands, with no apparent negative consequences, they can become routine accepted
practice. A perception that senior clinical staff and the management team are aware of the violation practices and are choosing to ignore them effectively reinforces the ongoing poor practice (Azim and McLaws 2014). Complete time out activity 4
Human factors strategies to improve hand hygiene There have been many strategies and interventions employed to improve hand hygiene practices. Sustained improvement has been patchy but, where there has been greater success, a combination of factors has been involved. System strategies that attempt to address the knowledge, environmental and work pressures that might lead to poor hand hygiene practices have been reported (Allegranzi et al 2010, Kirkland et al 2012, Stewardson and Pittet 2012). Knowledge of the cognitive processes that can lead to errors and deliberate violations provides the opportunity to identify strategies that deliberately target such processes to lessen the likelihood of errors. All strategies to improve hand hygiene require leadership, commitment and resourcing. This commitment must elevate hand hygiene as an organisational priority and ensure active role modelling of the requirements for effective hand hygiene are foremost in healthcare workers’ clinical practice (Stewardson and Pittet 2012).
Strategies targeting slips, lapses and mistakes
Strategies that focus on improving an individual healthcare worker’s understanding of the cognitive processes that lead to slips, lapses and mistakes provide insight into situational pressures and where errors are more likely to occur. One such strategy is Foresight Training, which encourages NHS staff to evaluate pressures during their daily work situations, in the realms of self, context and task, that may increase the likelihood of slips, lapses or mistakes occurring (Norris 2012). Staff are able to use this information to identify that they are at increased risk of making errors (Reason 2000, Boakes 2009). While this strategy is not specifically targeted at hand hygiene practices, it can highlight increased likelihood of errors in all domains of care. Having noted that lapses can be a major contributor to non-compliance as busy healthcare workers focus on their workload
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and forget to perform hand hygiene, Chassin et al (2015) suggest training coaches and peers to remind healthcare workers to wash their hands when appropriate. This could take the form of using a code word to alert peers to their lapse or some other form of discreet communication to remind others of the missed opportunity to perform hand hygiene. These coaches could also be used to reinforce education programmes on the rationale for effective hand hygiene. This may be more meaningful for some healthcare workers because the theoretical knowledge will be reinforced in relation to specific clinical settings and roles. Further opportunities to remind healthcare workers of the requirement for hand hygiene at the point of care could be provided during audits of hand hygiene rates. Currently, most reporting of hand hygiene compliance rates relies on observation of the number of actual performances of hand hygiene compared with the total number of times it should have been performed; the auditors avoid interactions with the healthcare workers being observed. There are potential problems with the veracity of observational audits because direct observation may result in rates being overstated; although there is no interaction between the healthcare workers and the auditor, healthcare workers are often aware of the presence of the auditor and this may lead to what is known as the Hawthorne effect, where an individual’s behaviour changes because they become aware of observation (Erasmus et al 2010). Srigley et al (2014) found support for this assertion in a study comparing hand hygiene observation rates with rates captured via electronic monitoring in the same clinical setting – the rate for the former was three times higher. However, Azim and McLaws (2014) propose that, rather than focusing on this discrepancy in reporting rates, the phenomenon of being reminded by the presence of the auditor to perform hand hygiene could be used as a formal improvement strategy. Therefore, the process of auditing could involve the auditor reminding the healthcare worker to perform hand hygiene when required, rather than recording non-compliance. The audits could record the number of times healthcare workers need to be reminded, rather than recording non-compliance. Visual cues such as posters and stickers also have a role in reminding healthcare workers of hand hygiene opportunities and techniques.
These, however, cease to be effective if they are not changed frequently because people become used to seeing them and cease to notice them over time (Filion et al 2011).
Strategies targeting violations
Appreciating that violations related to situational factors often occur because of a lack of available equipment at the point of care puts focus on the placement of washbasins and hand gel stations. These should be appropriately located in relation to the usual patterns of workflow, both in patients’ rooms and in corridors and work rooms. There should also be dedicated spaces where healthcare workers can place objects they may be carrying so they are able to perform hand hygiene (Chassin et al 2015). Complete time out activity 5 In hand hygiene violations where non-compliance has become routine and accepted practice, peer pressure and role modelling are determinants of hand hygiene compliance. In a study examining the role of doctors in determining the hand hygiene practices of the rest of the team, researchers found that, if the doctor performed hand hygiene, the compliance rate of the team was 66%, compared with 42% if this did not occur (Haessler et al 2012). The researchers also identified that it was not just doctors who could influence behaviour; regardless of role, if the first person in the team performed hand hygiene then it was more likely that others would do so (Haessler et al 2012). Complete time out activity 6 Involving patients and families in hand hygiene programmes provides an opportunity for the healthcare worker to be cued to the requirement for hand hygiene. While this sounds like a simple solution, there are many barriers to be overcome for patients to feel safe in challenging healthcare workers and for healthcare workers to respond appropriately to patients asking them to perform hand hygiene. Nevertheless, where patients were educated on admission to ask healthcare workers to wash their hands, hand hygiene showed significant improvement (Longtin et al 2010).
Conclusion Improving healthcare workers’ compliance with hand hygiene protocols is imperative if we are to reduce HCAI rates. Understanding the cognitive
5 Informally audit your workplace for the location of washbasins and hand gel stations. Are they where you are most likely to use them in relation to your workflow? Are there reminders visible by the washbasins and hand gel stations that demonstrate the correct technique for hand hygiene? Is there a place to put objects you may be carrying while you are performing hand hygiene? 6 Imagine you are about to replace a patient’s dressing and the patient asks if you have washed your hands. How do you think you would react? How do you think you would react if a colleague reminded you to perform hand hygiene before starting the dressing?
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CPD infection control
7 Now that you have completed the article, you might like to write a reflective account. Guidelines to help you are on page 50.
processes involved in undertaking tasks identifies those circumstances when healthcare workers may forget to wash their hands or perceive that hand hygiene is not necessary. It is important to recognise that, in situations where healthcare workers perceive low risk, deliberate hand hygiene violations can occur. In some areas, these violations can become
routine practice. Improvement in compliance with hand hygiene practices requires targeted interventions that address organisational constraints, training and education, and organisational safety culture, and also challenge healthcare workers’ perceptions of low risk that lead to hand hygiene protocol violations NS Complete time out activity 7
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