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

Foresight training: 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.

• Foresight training encourages NHS staff to evaluate pressures during their daily work situations, in the realms of self, context and task, where the likelihood of slips, lapses or mistakes occurring is increased (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.

Training coaches and peers: Chassin et al (2015) noted that lapses can be a major contributor to non-compliance, as busy healthcare workers focus on their workload and forget to perform hand hygiene. They suggest using 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.

Audits of hand hygiene rates: 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: these can include posters and stickers. Visual cues 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

Placement of equipment: 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

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?

Once completed your time out activity is saved and stored in "My Modules”.

Peer pressure and role modelling: 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

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?

Once completed your time out activity is saved and stored in "My Modules”.

Involvement of patients and families: 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).

Learning points

1. 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.
2. Strategies targeting slips, lapses and mistakes include: foresight training, training coaches and peers, audits and visual cues such as posters.
3. Foresight training encourages NHS staff to evaluate pressures during their clinical practice, in the realms of self, context and task that may increase the likelihood of slips, lapses or mistakes occurring.
4. Coaches could also be used to reinforce education programmes on the rationale for effective hand hygiene.
5. Violations related to situational factors often occur because of a lack of available equipment at the point of care.
6. In hand hygiene violations where non-compliance has become routine and accepted practice, peer pressure and role modelling are determinants of hand hygiene compliance.
7. Involving patients and families in hand hygiene programmes provides an opportunity for the healthcare worker to be reminded of the need for hand hygiene.