Hand Hygiene Compliance: The Workplace Environment

We continue our posts regarding the psychological aspects of the H1N1 flu by examining environmental aspects that can facilitate one of the best preventive measures – hand-washing.

#1 Easy Access; If it’s there, it’s used.

If companies want their employees to wash their hands more frequently, then they should ensure that sanitizers are easily available and that the washroom facilities are clean and well-stocked. Psychologists know that when barriers to entry for a desired behaviour are reduced, participation in that behaviour increases.

All forms of behaviour can be applied to this simple yet often underestimated phenomenon. Human behaviours are easily influenced by the availability or lack thereof of products. Most obviously, commodity providers make use of this principle to readily promote consumption. Rather problematic illustrations of this principle are replete in the literature on drug and alcohol consumption. For example, when access to beer and alcohol, either through lower price or increased store hours, is made easier, people buy more alcohol. When snack food is placed close at-hand either on the desk or close by, workers eat more. Conversely, when people have to get out of their chairs to walk to the food, less consumption occurs.

In theory, most people would use sanitizer, but rather than make people question whether a detour of several feet is worth the trouble, place the sanitizer on a stand in the middle of corridor or just after the door. Easy access promotes consumption, and making sanitizer readily available acts as constant reminder. I recently ran across a study in the American Journal of Infection Control, 2008, authored by an enterprising nurse-manager who borrowed an idea she saw in a mall -a large stainless steel tripod with automatic gel dispensers was placed outside the children’s play area with eye-catching publicity on each side. The manager modified the advertizing messages and placed the same impossible-to-miss hand hygiene dispenser mid-corridor resulting in dramatic improvements in hand sanitizing for hospital staff and visitors.

#2 Environmental Prompts; Tell me what to do.

Our well-connected occipital cortex makes us susceptible to visual cues that control all types of behaviour. In psychological jargon, this is called visual prompting. The rest of the world calls it signage.

Psychologists are not just known for jargon, we also measure. Therefore, readers of the 27^th issue of the Journal of Organizational Behavior Management will know that when drivers where presented with a visual prompt to drive safely as they exited a garage, the rate of correct turn-signaling at the next intersection jumped over 30%. Signs also work to encourage stair-climbing, they appear to work even more when their health benefits are made explicit as was reported by Drs Webb and Eves in Health Education Research.

To encourage proper hand-hygiene organizations should use signage to change behaviour. Here are some helpful links to appropriate signage:

http://images.google.ca/images?hl=en&q=hand+washing+posters&revid=2072946769

http://www.calgaryhealthregion.ca/pandemic/pdf/Pandemic11x17.pdfhttp://www.publichealth.va.gov/flu/materials/posters_hand_hygiene.asp

http://www.washinghands.net/posters-signs-pictures.php

Signage is especially important if we have to change group norms in the workplace. For example, if critical industries decide to eliminate or reduce hand-shaking, the signs to this effect need to be prominently displayed. In this way, the interpersonal stress of violating what was previously normative behaviour is significantly reduced.

But, People Make it Complicated; Nothing Like Peer Pressure

I would be remiss to report that despite easy access and witty messages, we humans also respond to pressure. We tend to do the right thing when we believe that others are also doing the right thing, and when we know that there is a potential that our behaviour might be checked. Think of income tax and the compliance-engendering effect of potential audits.

In this regard, Barrett and Randle, 2008, reported an interesting study that examined the reasons why nurses might not comply with proper hand-washing procedures even when they knew the benefits. Here was common quote:

It’s amazing how much you do copy what you see others doing,

especially if it’s your firrst placement you don’t want to upset anyone.

You mix in with the crowd and do what they’re doing. (Participant 1)

In other words, peer pressure counts. Companies have two choices. Most creatively, they can use managers and executives as role models. Think about an intranet YouTube-type video of your company CEO using sanitizer or washing her hands for the required 15 seconds.

Alternatively, your organization can create a company-wide culture that gives permission to employees from all ranks to point-out the short-comings of others. The question is how to do it? Probably not by stressing the short-comings such as:

Why don’t you use your sleeve!

But maybe by stressing the advantages to the individual:

It would be better for you to sneeze into your sleeve..

The H1N1 flu has dragged behaviours that once were clearly in the private and therefore unchallenged domain into the public or company arena. When an employee sneezes or coughs in an elevator, there is now more at stake. Companies that take the initiative in helping employees best respond with appropriate but non-argumentative statements will benefit.

And finally, want to get over 90% compliance to proper hand-washing, then The Jewish Hospital in Cincinnati has the solution -a Big but apparently friendly, Brother. Here’s the deal as reported in the American Journal of Infection Control where patient safety leaders randomly observed all manner of hospital employees, including physicians, vis-a -vis their hand hygiene practices. Infractions are noted and the associate informed in a discreet fashion. If things get serious, perhaps it should be considered.