How do HCWS, Patients and Consumers Think about Hand Hygiene in the Health Care Setting

1. Psychological Factors
of Hand Hygiene
Presented by:
Dr. Maryanne McGuckin, FSHEA

2. Disclosure
 Currently, McGuckin Methods International has a
consulting agreement for clinical trials with Hand-In-Scan.
 No material presented will be related to Hand-in-Scan
products.

3. McGuckin Methods International
 Mission: Pioneering effective methods for safe healthcare
delivery through research, education and advocacy.
 Academic Career: Faculty of the University of Pennsylvania

4. Psychological Factors: DEFINED
Psychological factors refer to:
 1. Thoughts
 2. Feelings
 3. Cognitive characteristics that affect the attitude,
behavior and functions of the human mind.
HCWs, Patients and Consumers have
different factors that affect HHC.

5. Dr. McGuckin’s Psychology on Hand Hygiene
Healthcare
Workers:
Just do it
Patients:
Just do it
for me
Consumers:
Empower
me
Researchers:
Focus on
positive and
what works
Be Passionate. Be Persuasive.

6. Learning Objectives
Review the
Status
• Review the status
of hand hygiene
(HH) compliance
Review
Current
Research
• Review the current
research and practice
regarding psychology
of hand hygiene by
HCW, Patient and
Consumer
Learn how to
be Persuasive

7. Healthcare Associated Infections (HAIs)
 Cost: Total annual costs for the 5 major infections: $9.8 billion
 JAMA Intern Med. 2013 Dec 9-23;173(22):2039-46.
 Cost when including social impact: $96-147 billion
 J Med Econ. 2013 Dec;16(12):1399-404.
 Burden: 1 out of every 25 patients in U.S. hospitals affected by
an HAI
 N Engl J Med. 2014 Mar 27;370(13):1198-208
 WHO Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire
at least one health care-associated infection
 Recent studies conducted in Europe reported hospital-wide
prevalence rates of patients affected by HAIs ranging from
4.6% to 9.3% (2013).

8. Compliance in U.S.: Multicenter
Despite overwhelming evidence that hand hygiene programs reduce
the spread of HAIs, compliance is at or below 50% - even after consistent
education, measurement and feedback.
Month
ICU
Compliance
Non-ICU
Compliance
Baseline 26% 36%
1 29% 36%
2 29% 39%
3 31% 39%
4 37% 44%
5 37% 46%
6 35% 45%
7 39% 49%
8 41% 49%
9 35% 48%
10 39% 47%
11 39% 48%
12 36% 51%
p = 0.0119 p < 0.0001
McGuckin M, Waterman R, Govednik J. Hand Hygiene Compliance in US. A Multicenter
Evaluation using Product Volume Measurement and Feedback. American Journal of
Medical Quality 24(3) 205-213 2009

9. What we know about HH Programs
Compliance programs must be MULTIMODAL:
 Product at point of care
 Education
 Intervention
 Measurement & Feedback
 Patient Participation
However, achieving significant
and sustained improvement
has been challenging.

10. HCW Psychological Factors:
Spontaneous or Determinative
Dr’s Lounge

11. How do HCWs Think?
We were trained to break down concepts into parts...but in complex systems –
like hand hygiene and health care delivery
 Relationships between parts are far greater than the parts alone
. Carla J. Alvarado, PhD Research Scientist Emerita University of Wisconsin-Madison

12. HCWs Psychology and HH
Applying psychological frameworks of behaviour change to
improve healthcare worker hand hygiene: a systematic review
Goal: To identify studies that used psychological theories of behaviour
change to increase or predict hand hygiene compliance among HCWs.
Theories:
1) Positive reinforcement
2) Change theory
3) Theory of planned behaviour
4) Transtheoretical model
5) Prediction studies based on the theory of planned behaviour, the transtheoretical model, and TDF
J.A. Srigley , *, K. Corace b, D.P. Hargadon D. Yu a, T. MacDonald , L. Fabrigar G.
Garber. Ontario JHI 2016.

13. Conclusion
No theory produced significant and sustained increases
 Studies have used models that are best suited to explain deliberative
behaviours.
 Hand hygiene is a repetitive, automatic behaviour and more of a habit.
 Hand hygiene is a spontaneous behaviour involving non-thoughtful behavioural
responses.
 Habit theories stress the importance of establishing strong automatic
associations between performance of a behaviour and cues at the time the
behaviour is initially started and that these cues are present in the
environment where the behaviour will later be performed
What might these clues be???
Always there and always replaced.
Provide education at time of performance.

14. Factors That Influence
Physician Hand Hygiene Compliance
TDF: 42 physician interviews, 14 domains
 9 domains reported, based on Pittet work:
 Knowledge
 Skills
 Beliefs about capabilities
 Beliefs about consequences
 Goals
 Memory
 Attention and decision processes
 Environmental context and resources
 Social influences

15. “Priming” Hand Hygiene Compliance in
Clinical Environments
Priming in terms of psychology refers to the effects of some
event or action on subsequent associated response
Control group - 404
Two phases: olfactory (160) and visual (124)
Control group: 15% HHC
Olfactory: 46% HHC
Visual: Male eyes: 33%; Female:10% HHC
Top: Female
Bottom: Male
D., Vlaev, I., Everett-Thomas, R., Fitzpatrick, M., Darzi, A., & Birnbach, D. J.
(2015, July 27). “Priming” Hand Hygiene Compliance in Clinical Environments.
Health Psychology.Advance online publication

16. Theory of Obedience and Role Modeling
Voice Prompts: ICU
 “We want 100% HH Compliance in
our ICU.”
 “Remember handwashing before
and after patient contact.”
 “Gloves do not replace hand
hygiene.”
McGuckin M. The Effect of Random Voice Hand Hygiene Messages Delivered By
Medical, Nursing and Infection Control Staff On Hand Hygiene Compliance In
Intensive Care. AJIC. 2006
Significant increase in hand sanitizer by HCW and visitor

17. It’s Not All About Me: Motivating Hand Hygiene
Among Health Care Professionals by Focusing on
Patients: Psychological Science 22(12) 1494–1499
Personal Safety versus Patient Safety: Persuasion Theory Using Reminders
of Patient Consequences
 HCW sign, “Hand hygiene prevents you from catching diseases.”
 The patient-consequences sign, “Hand hygiene prevents patients from
catching diseases.”
 The control sign, which was developed by hospital managers, “Gel in,
wash out.”
The patient-consequences sign produced an increase of more than 45% in the amount
of hand-hygiene product used per dispenser and an increase of more than 10% in HHC.
Grant and Hoffman Management Department, The Wharton School, University of Pennsylvania, and 2Kenan-Flagler
Business School, University of North Carolina at Chapel Hill

18. Patient Psychological Factors
“Patients should be sure that
any Physician, Nurse,
Therapist, has washed
his/her hands before
touching them.”
McGuckin, M., Medical World News,
2-15-82

19. 27 Years Later!!!!
"A process in which patients understand their
role, are given the knowledge and skills by
their health-care provider to perform a task
in an environment that recognizes
community and cultural differences and
encourages patient participation.”
WHO Guidelines on Hand Hygiene
in Health Care (2009)
Health empowerment emphasizes facilitating one’s
awareness of the ability to participate knowingly in health
and health care decisions.

20. Evidence That Empowerment Works
Acute care - McGuckin, et al, AJIC 1999;27:309-14
McGuckin, et al, JOIC 2001;48:222-227
Acute Care Oxford, UK - McGuckin M. The Journal of Hospital Infection,
48:222-227 2001.
LTC - McGuckin, et al, The Director 2004,Vol 12;(1):14-17
Rehabilitation - McGuckin, et al, Am J Infect Control 2004;32:235-8
ICU - McGuckin, et al, Am J Infect Control Dec 2006

21. PIYC Empowerment Model Evaluation
1997-2006
Year Location Source Impact
1997 US, multicenter McGuckin et. al. Patient Education Model for Increasing Handwashing Compliance. Am J Infect Control 1999. + 34% HH/bd
1998 Oxford, UK McGuckin et. al. Evaluation of Patient Empowering Hand Hygiene Programme in UK. J Hosp Infec 2001. + 40% HH/bd
1999 Norway 5 hospitals + 40% HH/bd
2000 Denmark 5 hospitals + 35% HH/bd
2001 Netherlands 2 hospitals + 50% HH/bd
2001-2 Germany 20 hospitals + 40% HH/bd
2002 Switzerland 2 hospitals + 45% HH/bd
2003 US rehabilitation
hospital.
McGuckin et. al. Evaluation of a Patient Education Model for Increasing Hand Hygiene Compliance in an In-
Patient Rehabilitation Unit. Am J Infect Control 2004.
+ 56% HH/bd
2005 Long Term Care McGuckin, et. al. Validation of a Comprehensive Infection Control Program in LTC The Director 2004. + 52% HH/bd
2005 US McGuckin et al. Consumer attitudes about health care-acquired infections and hand hygiene. Am J Med Qual.
2006.
80% would ask
2006 ICU McGuckin, et. al. The Effect of Random Voice Hand Hygiene Messages Delivered by Medical, Nursing, and
Infection Control Staff on Hand Hygiene Compliance in Intensive Care Am J Infect Control 2006.
+ 100% sanitizer use
HH/bd = Hand Hygiene occurrences per patient bed day

22. DO PATIENTS WANT TO BE EMPOWERED?
National Telephone Survey – U.S.
80% (4/5) respondents said they would ask
their HCW to wash hands if encouraged by staff
52% respondents saw HCW put on gloves rather
than practice HH
McGuckin M, et al. Consumer Attitudes About Healthcare-Acquired Infections and Hand Hygiene. Amer Journal of
Med Quality. 21:1-5, 2006

23. 2007 Survey
If your doctor, nurse or other person providing healthcare to you, DID NOT ASK or invite you to remind them to wash/sanitize
their hands before examining you, would you feel comfortable asking them to wash/sanitize their hands?
If your doctor, nurse or other person providing healthcare to you ASKED or invited you to remind them to wash/sanitize their
hands before examining you, would you feel able to do this?
If you saw your doctor or nurse taking care of the patient next to you and then coming to you without washing or sanitizing
their hands, would you ask them to do so?
YES
0
10
20
30
40
50
60
70
80
90
100
Overall USA Canada Overall USA Canada Overall USA Canada
58.3%
69.8%
47.8%
86.9%
94.9%
84.8%
80.6%
90.5%
65.2%

24. Conclusion
Most patients believe that they should be involved
in hand hygiene
29%
71%
Patients should not be involved Patients should be involved
Source: National Patient Safety Agency

25. Willingness: Patients want Empowerment!
 These show intention, not action.
 Missing link: HCW explicit permission to ask
57%
43%
1989:
Pay for IC information1
Yes No
70%
30%
1999-2005
Ask about HH2
Yes No
71%
29%
2005:
Involved in HH3
Yes No
80%
20%
2006:
Ask if given
permission4
Yes No
Sources (left to right): 1) P.J. Miller, B.M. Farr. Survey of patients’ knowledge of nosocomial infections. Am J
Infect Control 1989;17:31-4.; 2) McGuckin various studies, 3) National Health Service. National Patient Safety
Guide Cleanyourhands campaign supporting resource 28 – Staff Guide to Patient Involvement, 4) McGuckin M,
Waterman R, Shubin A. Consumer attitudes about health care-acquired infections and hand hygiene. Am J Med
Qual. 2006 Sep-Oct;21(5):342-6.

26. Evidence for HCW Explicit Permission
Study origin
Patient believes he/she
should be involved
Patient would ask about
hand hygiene
Would Ask if HCW
permission to patient
England and Wales NPSA (2004)1 71% 26% Not measured (N/M)
Ontario (Canada)2 32% 42% N/M
USA consumer survey3 N/M N/M 80%
USA web survey4 N/M 60% N/M
World Health Organization survey5 N/M 52% 86%
UK6 79%
N/M
N/M
USA7 91% 45% N/M
UK8 Significant increase
Switzerland9 N/M 33% 81%
Australia10 90% 40% N/M

27. HCW Explicit Permission to Patients
How useful do you think the following interventions would be in encouraging
hand hygiene? Results combined from patients, healthcare workers, and
coordinators. (N=1115 participants)
Pittet D, Panesar SS, Wilson K, Longtin Y, Morris T, Allan V, Storr J, Cleary K, Donaldson L. Involving the patient to ask about hospital
hand hygiene: a National Patient Safety Agency feasibility study. J Hosp Infect. 2011 Apr;77(4):299-303.

28. Ask Me to Sanitize or Wash My Hands
 THE PSYCHOLOGICAL THEORIES OF INFLUENCE AND PERSUASION
http://changingminds.org/explanations/theories/a_clusters.htm

29. A Review of Electronic Hand Hygiene Monitoring:
Considerations for Hospital Management in Data Collection,
Healthcare Worker Supervision, and Patient Perception
 Patient Perception on Electronic Devices: not much research.
 One study: Michaelse, Sanders, Zimmer, and Bump (2013)
 Flashing alerts worn by HCW versus brochure on admission on HAIs (93% liked
alert versus 7% brochure)
BUT
90% would not seek care from doctor that did not perform HH
and 60% would not go to that hospital.
McGuckin et al. Journal of HealtHcare ManageMent 60:5 SepteMber/october 2015

30. Consumer Awareness
IF ONLY I KNEW

31. Consumer perceptions of healthcare
associated infection and hand hygiene
- a global survey
Claire Kilpatrick, Director S3 Global
Consultant to the World Health Organisation
@safesafersafest @claireekt @WHO
Dr. Maryanne McGuckin
McGuckin Methods International
www.mcguckinmethods.com @drmcguckin
Hosted by Jules Storr
World Health Organization
Sponsored by
WHO Patient Safety Challenge Clean Care
is Safer Care
www.webbertraining.com

32. Consumers and Health Care
If consumers make decisions about their health care choices,
would they consider hand hygiene/infection standards as
part of this decision making?
 A telephone survey was conducted: N=1001
 Ireland (n=250), India (n=251), Mexico (n=251) and Hong
Kong (n=249), were surveyed
 The period of study was October 22-29, 2014

33. The majority of respondents surveyed believe that health workers clean
their hands at the right times when treating or caring for patients. This
belief is highest among those in Hong Kong, followed by India.
A1: Do you think that health workers (e.g. nurses and doctors) in hospitals and other settings (for example, clinics) clean their hands at
the right times when treating/caring for patients? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

34. The majority of those who believe health care workers clean their hands
at the right time believe they do so all of the time, except among those
in Ireland. In Ireland, the majority believe it’s just some of the time.
A2: Do you think that health workers are cleaning their hands at the right time…? Base=Think health workers clean their hands at the
right time (Hong Kong=200, India=167, Ireland=133, Mexico=143)

35. Those in India are most likely to have asked a health worker about clean
hands with respect to a visit or treatment they were receiving. Those in
Mexico are second most likely to have asked, followed by those in Hong
Kong. Very few in Ireland have asked.
A4: Have you ever asked an individual physician (doctor), nurse or other health worker, or a health care organization (e.g. hospital or
clinic) any questions about this subject of clean hands with respect to a hospital/clinic visit or treatment you were receiving? (Hong
Kong=249, India=251, Ireland=250, Mexico=251)

36. Responses to questions about health workers cleaning their hands at the
right time were based on respondents’ own personal experience for at
least seven out of ten. Significantly fewer responses were based on
information from friends and relatives, and few were based on media.
A3: Were your answers to the previous questions based on…? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

37. When asked what they think happens if the hands of health workers are
not cleaned at the right time before touching patients, more than four in
five said that germs are spread to patients. Half said the health worker
might get sick. Those in Hong Kong are least to think patients might be
seriously harmed or even die, germs may spread to family members, or
infections are passed on to patients.
A5: What do you think happens if the hands of nurses/doctors/other health workers are not cleaned at
the right time before touching patients? (Hong Kong=249, India=251, Ireland=250, Mexico=251)

38. AWARENESS, ENGAGEMENT AND INTENT
 How the Consumer Uses These Actions
 Demographic Characteristics of Consumer
Public Reporting of Health Care–Associated Infection Rates
Maryanne McGuckin, DrScEd, FSHEA, John Govednik, MS, David Hyman, JD, MD, Bernard Black, JD
American Journal of Medical Quality
Vol 29, Issue 1, pp. 83 – 85: July-23-2013

39. Consumer Results (Cont’d)
1P = 0.0248 2P=0.0011 3P=0.0002 4P = 0.0143 5P = 0.0183 6P = 0.8620

40. Consumer Results (Cont’d)
Awareness Engagement Intention
Educ High Sch 32% 8% 58%
College 40% 12% 50%
Post Grad 47% 18% 47%
More educ more
aware1
More educ more
engaged2
More educ less
intent3
Inc <$25,000 30% 9% 60%
$25-59,999 39% 12% 55%
$60-99,999 41% 12% 48%
$100,000+ 46% 16% 43%
More income more
aware4
Not significant5 More income less
intent6
1P < 0.0001 2P < 0.0001 3P < 0.0001 4P = 0.0007 5P = 0.0928 6P < 0.0001

41. Consumer Results (Cont’d)
1P=0.0001 2P < 0.0001 3P<0.0001

42. Persuasive Theory
 Healthcare workers are empowered
when they educate patients and
invite them to ask questions
 Patients are empowered by
participating in decisions helping to
address medical errors
Further reading: McGuckin M, Storr J, Longtin Y,
Allegranzi B, Pittet D. Patient empowerment and
multimodal hand hygiene promotion: a win-win
strategy. Am J Med Qual. 2011 Jan-Feb;26(1):10-7.
A FORM OF COMMUNICATION THAT AIMS AT
MESSAGES THAT SUBTLY CHANGE THE
ATTITUDE OF THE RECEIVER.

43. Steps of Persuasion Process
 As proposed by Professor Jay Conger, the following are the steps to be
followed in the Persuasion Process:
• Step 1: Establish Credibility and Trust in Yourself
• Step 2: Find a Basis of Common Ground
• Step 3: Provide Vivid Proof
• Step 4: Connect at an Emotional Level
Let us look
at each in
detail.

44. Step 1: Establish Credibility and Trust in Yourself
The first step of the ‘Persuasion Process’ is to establish credibility and trust in yourself
in the minds of the audience. You can do this by using your expertise and knowledge in
the field that you are speaking about, by building and then appealing to the strong
relationships that you share with your audience, by carefully listening to others and
their opinions and by using your history of good judgement to appeal to each person’s
individual personality.

45. Step 2: Find a Basis of Common Ground
In this step you must highlight the advantages that the people you are trying to
persuade would experience. In order to do that, you must thoroughly understand the
challenges that your audience faces, and what they most care about. A common
ground cannot be an idea or solution that is good for its own sake.

46. Step 3: Provide Vivid Proof
This step involves presenting your audience with vivid or clear proofs to support your
statements and opinion. You can use logic and facts to support your statements, using
imagery and metaphors to help other person compare and understand your opinions.
You can use stories and examples to help other person associate with your ideas and
feelings. You may use numbers to prove your statements by presenting spreadsheets to
support your statements.

47. Step 4: Connect at an Emotional Level
This step involves connecting with the other person at an emotional level. You should
understand the tangents or aspects to the person’s personality. You should show
empathy and your respect for their feelings and opinions. You should show your
commitment, honesty and dedication. In order to connect at an emotional level, you
should have a high degree of self-awareness so that you can understand your own
emotions as well as the other person’s emotions.

48. Conclusion: “I Never Thought of it
That Way!”
 It is human nature not to believe something is possible if
it doesn’t fit into the current view.
 Our current view on HH compliance has become focused
on technology and trying to show what does not work
rather than focusing on human nature.
Beyond Empowerment: Patients, Paradiggms, and Social Moveements.
PSQH, Vol 13, Issue 2 April 2016

49. Are we Overthinking HHC?
Two-step process: Quantitative and Qualitative
 1.Quantitiative: Get HCWs to the sink/product at the right times
THEN
 2 .Qualitative: Educate and monitor technique.
Hand Hygiene Procedures

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duplicated or used without permission. .

51. THANK YOU.